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Threatened efficiency not autonomy: Prescriber perceptions of an established pediatric antimicrobial stewardship program. Infect Control Hosp Epidemiol 2019; 40:522-527. [PMID: 30919799 DOI: 10.1017/ice.2019.47] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Implementing antimicrobial stewardship programs (ASPs) can be challenging due to prescriber resistance. Although barriers to implementing new ASPs have been identified, little is known about how prescribers perceive established programs. This information is critical to promoting the sustainability of ASPs. OBJECTIVE To identify how prescribers perceive an established pediatric inpatient ASP that primarily utilizes prior authorization. METHODS We conducted a cross-sectional survey administered from February through June 2017 in a large children's hospital. The survey contained closed- and open-ended questions. Descriptive statistics and thematic content analysis approaches were used to analyze responses. RESULTS Of 394 prescribers invited, 160 (41%) responded. Prescribers had an overall favorable impression of the ASP, believing that it improves the quality of care (92.4% agree) and takes their judgment seriously (73.8%). The most common criticism of the ASP was that it threatened efficiency (26.0% agreed). In addition, 68.7% of respondents reported occasionally engaging in workarounds. Analysis of 133 free-text responses revealed that prescribers perceived that interacting with the ASP involved too many phone calls, caused communication breakdowns with the dispensing pharmacy, and led to gaps between approval and dispensing of antibiotics. Reasons given for workarounds included not wanting to change therapy that appears to be working, consultant disagreement with ASP recommendations, and the desire to do everything possible for patients. CONCLUSIONS Prescribers had a generally favorable opinion of an established ASP but found aspects to be inefficient. They reported engaging in workarounds occasionally for social and emotional reasons. Established ASPs should elicit feedback from frontline prescribers to optimize program impact.
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Goulopoulos A, Rofe O, Kong D, Maclean A, O'Reilly M. Attitudes and beliefs of Australian emergency department clinicians on antimicrobial stewardship in the emergency department: A qualitative study. Emerg Med Australas 2019; 31:787-796. [PMID: 30920181 DOI: 10.1111/1742-6723.13251] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 12/31/2018] [Accepted: 01/20/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To explore the attitudes and beliefs of Australian ED clinicians towards antimicrobial stewardship in the ED. METHODS Semi-structured one-to-one interviews were conducted with ED clinicians between March and October 2015. Participants were identified via purposive and snowball sampling. Questionnaires were developed using the literature. Interviews were audio-recorded, transcribed and analysed using thematic analysis via the framework approach. Two researchers coded independently, with one using QSR International's NVivo 10 software and the other manually. Emergent themes were identified and classified. RESULTS Twenty-two clinicians (eight doctors, eight nurses and six pharmacists) from seven institutions participated. Participants were aware and concerned about antimicrobial resistance. Clinicians were divided based on their opinion on whether antimicrobials are prescribed appropriately and judiciously in the ED, with many perceiving prescribing to be inappropriate. Prior knowledge of the term 'Antimicrobial Stewardship' was demonstrated by doctors and pharmacists, with a relative lack of awareness by nurses. Four main themes were identified as both barriers and facilitators to antimicrobial stewardship in the ED: individual healthcare provider, resource, organisational and cultural. Uncertainty of diagnosis, time and resource pressures, reliance on previous experience and lack of access to expert opinion were perceived barriers. To facilitate appropriate prescribing, clinicians emphasised the need for routine education and feedback, adequate staffing, robust guidelines, senior medical clinician advocacy and multidisciplinary support. CONCLUSIONS Australian ED clinicians were aware of antimicrobial resistance. Many perceive injudicious antimicrobial use as problematic. Consideration of ED clinicians' perceived barriers and facilitators might enhance implementation of antimicrobial stewardship programmes in EDs.
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Affiliation(s)
- Anne Goulopoulos
- Pharmacy Department, Eastern Health, Melbourne, Victoria, Australia
| | - Olivia Rofe
- Pharmacy Department, Eastern Health, Melbourne, Victoria, Australia
| | - David Kong
- Centre for Medicine Use and Safety, Monash University, Melbourne, Victoria, Australia.,Ballarat Health Services, Ballarat, Victoria, Australia.,The National Centre for Antimicrobial Stewardship, Peter Doherty Institute, Melbourne, Victoria, Australia
| | - Andrew Maclean
- Emergency Services, Box Hill Hospital, Eastern Health, Melbourne, Victoria, Australia
| | - Mary O'Reilly
- Monash University, Melbourne, Victoria, Australia.,Infectious Diseases Department, Eastern Health, Melbourne, Victoria, Australia
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Differences in work environment for staff as an explanation for variation in central line bundle compliance in intensive care units. Health Care Manage Rev 2019; 43:138-147. [PMID: 27819803 DOI: 10.1097/hmr.0000000000000134] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Central line-associated bloodstream infections (CLABSIs) are a common and costly quality problem, and their prevention is a national priority. A decade ago, researchers identified an evidence-based bundle of practices that reduce CLABSIs. Compliance with this bundle remains low in many hospitals. PURPOSE The aim of this study was to assess whether differences in core aspects of work environments-workload, quality of relationships, and prioritization of quality-are associated with variation in maximal CLABSI bundle compliance, that is, compliance 95%-100% of the time in intensive care units (ICUs). METHODOLOGY/APPROACH A cross-sectional study of hospital medical-surgical ICUs in the United States was done. Data on work environment and bundle compliance were obtained from the Prevention of Nosocomial Infections and Cost-Effectiveness Refined Survey completed in 2011 by infection prevention directors, and data on ICU and hospital characteristics were obtained from the National Healthcare Safety Network. Factor and multilevel regression analyses were conducted. FINDINGS Reasonable workload and prioritization of quality were positively associated with maximal CLABSI bundle compliance. High-quality relationships, although a significant predictor when evaluated apart from workload and prioritization of quality, had no significant effect after accounting for these two factors. PRACTICE IMPLICATIONS Aspects of the staff work environment are associated with maximal CLABSI bundle compliance in ICUs. Our results suggest that hospitals can foster improvement in ensuring maximal CLABSI bundle compliance-a crucial precursor to reducing CLABSI infection rates-by establishing reasonable workloads and prioritizing quality.
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Alghamdi S, Atef-Shebl N, Aslanpour Z, Berrou I. Barriers to implementing antimicrobial stewardship programmes in three Saudi hospitals: Evidence from a qualitative study. J Glob Antimicrob Resist 2019; 18:284-290. [PMID: 30797087 PMCID: PMC7104169 DOI: 10.1016/j.jgar.2019.01.031] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 01/09/2019] [Accepted: 01/25/2019] [Indexed: 11/17/2022] Open
Abstract
Adoption of ASPs in Saudi hospitals remains low despite a national implementation strategy. Lack of enforcement of policies and guidelines is a main contributor to inappropriate antimicrobial prescribing. Barriers to ASP adoption in Saudi hospitals are mainly organisational. Physicians’ fears and concerns inhibit their adoption of antimicrobial stewardship practices.
Objectives This study explored antimicrobial stewardship programme (ASP) team members’ perspectives regarding factors influencing the adoption and implementation of these programmes in Saudi hospitals. Methods This was a qualitative study based on face-to-face semistructured interviews with healthcare professionals involved in ASPs and activities across three Ministry of Health (MoH) hospitals in Saudi Arabia (n = 18). Interviews were also conducted with two representatives of a General Directorate of Health Affairs in a Saudi region and two representatives of the Saudi MoH (n = 4) between January–February 2017. Results Despite the existence of a national strategy to implement ASPs in Saudi MoH hospitals, their adoption and implementation remains low. Hospitals have their own antimicrobial stewardship policies, but adherence to these is poor. ASP team members highlight that lack of enforcement of policies and guidelines from the MoH and hospital administration is a significant barrier to ASP adoption and implementation. Other barriers include disintegration of teams, poor communication, lack of recruitment/shortage of ASP team members, lack of education and training, and lack of health information technology (IT). Physicians’ fears and concerns in relation to liability are also a barrier to their adoption of ASPs. Conclusion This is the first qualitative study exploring barriers to ASP adoption and implementation in Saudi hospitals from the perspective of ASP team members. Formal endorsement of ASPs from the MoH as well as hospital enforcement of policies and provision of human and health IT resources would improve the adoption and implementation of ASPs in Saudi hospitals.
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Affiliation(s)
- Saleh Alghamdi
- Department of Clinical & Pharmaceutical Sciences, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK; Department of Clinical Pharmacy, Faculty of Clinical Pharmacy, Albaha University, Albaha, Saudi Arabia
| | - Nada Atef-Shebl
- Department of Clinical & Pharmaceutical Sciences, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
| | - Zoe Aslanpour
- Department of Clinical & Pharmaceutical Sciences, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
| | - Ilhem Berrou
- Faculty of Health & Applied Sciences, University of the West of England, Staple Hill, Bristol BS16 1DD, UK.
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55
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Kaljee LM, Prentiss T, Zervos M. Physician barriers to implementation of hospital-based antimicrobial stewardship programs (ASPs): a global perspective. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2019. [DOI: 10.1007/s40506-019-0183-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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56
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Hand J. Strategies for Antimicrobial Stewardship in Solid Organ Transplant Recipients. Infect Dis Clin North Am 2018; 32:535-550. [PMID: 30146022 DOI: 10.1016/j.idc.2018.04.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Complications of antimicrobial therapy, such as multidrug-resistant organisms and Clostridium difficile, commonly affect solid-organ transplant recipients and have been associated with graft loss and mortality. Although opportunities are abundant, antimicrobial stewardship practices guiding appropriate therapy have been infrequently reported in transplant patients. A patient-centered, multidisciplinary structure, using established antimicrobial optimization principles, is needed to create nuanced approaches to protect patients and antimicrobials and improve outcomes.
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Affiliation(s)
- Jonathan Hand
- Department of Infectious Diseases, The University of Queensland School of Medicine, Ochsner Clinical School, Ochsner Medical Center, 1514 Jefferson Highway, New Orleans, LA 70121, USA.
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57
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Gebretekle GB, Haile Mariam D, Abebe W, Amogne W, Tenna A, Fenta TG, Libman M, Yansouni CP, Semret M. Opportunities and barriers to implementing antibiotic stewardship in low and middle-income countries: Lessons from a mixed-methods study in a tertiary care hospital in Ethiopia. PLoS One 2018; 13:e0208447. [PMID: 30571688 PMCID: PMC6301706 DOI: 10.1371/journal.pone.0208447] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 11/16/2018] [Indexed: 01/21/2023] Open
Abstract
Background Global action plans to tackle antimicrobial resistance (AMR) include implementation of antimicrobial stewardship (AMS), but few studies have directly addressed the challenges faced by low and middle-income countries (LMICs). Our aim was to explore healthcare providers’ knowledge and perceptions on AMR, and barriers/facilitators to successful implementation of a pharmacist-led AMS intervention in a referral hospital in Ethiopia. Methods Tikur Anbessa Specialized Hospital (TASH) is an 800-bed tertiary center in Addis Ababa, and the site of an ongoing 4-year study on AMR. Between May and July 2017, using a mixed approach of quantitative and qualitative methods, we performed a cross-sectional survey of pharmacists and physicians using a pre-tested questionnaire and semi-structured interviews of purposively selected respondents until thematic saturation. We analyzed differences in proportions of agreement between physicians and pharmacists using χ2 and fisher exact tests. Qualitative data was analyzed thematically. Findings A total of 406 survey respondents (358 physicians, 48 pharmacists), and 35 key informants (21 physicians and 14 pharmacists) were enrolled. The majority of survey respondents (>90%) strongly agreed with statements regarding the global scope of AMR, the need for stewardship, surveillance and education, but their perceptions on factors contributing to AMR and their knowledge of institutional resistance profiles for common bacteria were less uniform. Close to 60% stated that a significant proportion of S. aureus infections were caused by methicillin-resistant strains (an incorrect statement), while only 48% thought a large proportion of gram-negative infections were caused by cephalosporin-resistant strains (a true statement). Differences were noted between physicians and pharmacists: more pharmacists agreed with statements on links between use of broad-spectrum antibiotics and AMR (p<0.022), but physicians were more aware that lack of diagnostic tests led to antibiotic overuse (p<0.01). More than cost, fear of treatment failure and of retribution from senior physicians were major drivers of antibiotic prescription behavior particularly among junior physicians. All respondents identified high turnover of pharmacists, poor communication between the laboratory, pharmacists and clinicians as potential challenges; but the existing hierarchical culture and academic setting were touted as opportunities to implement AMS in Ethiopia. Conclusions This knowledge and perceptions survey identified specific educational priorities and implementation strategies for AMS in our setting. This is likely also true in other LMICs, where expertise and infrastructure may be lacking.
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Affiliation(s)
| | - Damen Haile Mariam
- School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Workeabeba Abebe
- Department of Pediatrics and Child Health, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Wondwossen Amogne
- Department of Internal Medicine, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Admasu Tenna
- Department of Internal Medicine, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Teferi Gedif Fenta
- School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Michael Libman
- Department of Medicine, Infectious Diseases and Microbiology, and JD MacLean Centre for Tropical Diseases, McGill University Health Centre, Montreal, Quebec, Canada
| | - Cedric P. Yansouni
- Department of Medicine, Infectious Diseases and Microbiology, and JD MacLean Centre for Tropical Diseases, McGill University Health Centre, Montreal, Quebec, Canada
| | - Makeda Semret
- Department of Medicine, Infectious Diseases and Microbiology, and JD MacLean Centre for Tropical Diseases, McGill University Health Centre, Montreal, Quebec, Canada
- * E-mail:
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58
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Alghamdi S, Shebl NA, Aslanpour Z, Shibl A, Berrou I. Hospital adoption of antimicrobial stewardship programmes in Gulf Cooperation Council countries: A review of existing evidence. J Glob Antimicrob Resist 2018; 15:196-209. [DOI: 10.1016/j.jgar.2018.07.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 07/12/2018] [Accepted: 07/19/2018] [Indexed: 10/28/2022] Open
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Poole NM. Judicious antibiotic prescribing in ambulatory pediatrics: Communication is key. Curr Probl Pediatr Adolesc Health Care 2018; 48:306-317. [PMID: 30389361 DOI: 10.1016/j.cppeds.2018.09.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Children in outpatient clinics are prescribed over 15 million courses of unnecessary antibiotics annually. Clinicians have identified parent pressure for antibiotics, parent satisfaction, and time constraints as the primary drivers of unnecessary antibiotic prescribing. Over the past decade, parents have become more aware that antibiotics only treat bacterial infections, yet continue to report an expectation for antibiotics in 50-65% of acute care visits. Parental expectations for antibiotics stem from parental concerns about symptom severity and a desire to alleviate symptoms. Clinicians can address parental concerns when they assess the severity of illness through a physical exam, provide a clear explanation for the symptoms, recommend ways to alleviate the symptoms, and provide council on when to be concerned. When clinicians fail to address parental concerns, parents are more likely to challenge the diagnosis or treatment recommendations, clinicians are more likely to perceive that parent as expecting an antibiotic, and antibiotics are significantly more likely to be prescribed. Parents that expect antibiotics are more likely to communicate using a 'candidate diagnosis' (e.g., "Johnny has strep throat.") and resist the diagnosis or treatment given. Clinicians can recognize these parental communication patterns and use specific communication practices shown to decrease unnecessary antibiotic prescribing. When parents expect antibiotics, clinicians should (1) review physical exam findings using 'no problem' commentary (e.g., "This ear is just a little red."), (2) deliver a specific diagnosis (e.g., avoid 'a virus'), (3) use a two-part negative/positive treatment recommendation (e.g., "On the one hand, antibiotics will not help. On the other hand, ibuprofen can help with pain."), and (4) provide a contingency plan. Clinicians should feel comfortable discussing the risks and benefits of antibiotics. Effective communication between parents and clinicians in outpatient clinics leads to more judicious antibiotic prescribing, higher parent satisfaction scores, and more efficient clinic visits.
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Affiliation(s)
- Nicole M Poole
- Seattle Children's Research Institute, Seattle, WA, United States; University of Washington, Seattle, WA, United States; Seattle Children's Hospital, Seattle, WA, United States.
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60
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Chou AF, Graber CJ, Zhang Y, Jones M, Goetz MB, Madaras-Kelly K, Samore M, Glassman PA. Specifying an implementation framework for Veterans Affairs antimicrobial stewardship programmes: using a factor analysis approach. J Antimicrob Chemother 2018; 73:2559-2566. [PMID: 29873721 DOI: 10.1093/jac/dky207] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 05/06/2018] [Indexed: 11/14/2022] Open
Abstract
Objectives Inappropriate antibiotic use poses a serious threat to patient safety. Antimicrobial stewardship programmes (ASPs) may optimize antimicrobial use and improve patient outcomes, but their implementation remains an organizational challenge. Using the Promoting Action on Research Implementation in Health Services (PARiHS) framework, this study aimed to identify organizational factors that may facilitate ASP design, development and implementation. Methods Among 130 Veterans Affairs facilities that offered acute care, we classified organizational variables supporting antimicrobial stewardship activities into three PARiHS domains: evidence to encompass sources of knowledge; contexts to translate evidence into practice; and facilitation to enhance the implementation process. We conducted a series of exploratory factor analyses to identify conceptually linked factor scales. Cronbach's alphas were calculated. Variables with large uniqueness values were left as single factors. Results We identified 32 factors, including six constructs derived from factor analyses under the three PARiHS domains. In the evidence domain, four factors described guidelines and clinical pathways. The context domain was broken into three main categories: (i) receptive context (15 factors describing resources, affiliations/networks, formalized policies/practices, decision-making, receptiveness to change); (ii) team functioning (1 factor); and (iii) evaluation/feedback (5 factors). Within facilitation, two factors described facilitator roles and tasks and five captured skills and training. Conclusions We mapped survey data onto PARiHS domains to identify factors that may be adapted to facilitate ASP uptake. Our model encompasses mostly mutable factors whose relationships with performance outcomes may be explored to optimize antimicrobial use. Our framework also provides an analytical model for determining whether leveraging existing organizational processes can potentially optimize ASP performance.
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Affiliation(s)
- Ann F Chou
- Department of Family and Preventive Medicine, College of Medicine, University of Oklahoma, 900 NE 10th St., Oklahoma City, OK 73104, USA.,The VA HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System Los Angeles, 11301 Wilshire Blvd, Los Angeles, CA 90073, USA
| | - Christopher J Graber
- The VA HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System Los Angeles, 11301 Wilshire Blvd, Los Angeles, CA 90073, USA.,David Geffen School of Medicine at UCLA, Los Angeles, Box 951691, Los Angeles, CA 90095, USA
| | - Yue Zhang
- Department of Internal Medicine and Division of Epidemiology, University of Utah, 295 Chipeta Way, Salt Lake City, UT 84108, USA.,VA Salt Lake City Healthcare System, 500 S Foothill Drive, Salt Lake City, UT 84148, USA
| | - Makoto Jones
- Department of Internal Medicine and Division of Epidemiology, University of Utah, 295 Chipeta Way, Salt Lake City, UT 84108, USA.,VA Salt Lake City Healthcare System, 500 S Foothill Drive, Salt Lake City, UT 84148, USA
| | - Matthew Bidwell Goetz
- The VA HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System Los Angeles, 11301 Wilshire Blvd, Los Angeles, CA 90073, USA.,David Geffen School of Medicine at UCLA, Los Angeles, Box 951691, Los Angeles, CA 90095, USA
| | - Karl Madaras-Kelly
- Boise Veterans Affairs Medical Center, 500 W Fort Street, Boise, ID, USA.,College of Pharmacy, Idaho State University, 1311 E Central Drive, Meridian, ID 83642, USA
| | - Matthew Samore
- Department of Internal Medicine and Division of Epidemiology, University of Utah, 295 Chipeta Way, Salt Lake City, UT 84108, USA.,VA Salt Lake City Healthcare System, 500 S Foothill Drive, Salt Lake City, UT 84148, USA
| | - Peter A Glassman
- The VA HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System Los Angeles, 11301 Wilshire Blvd, Los Angeles, CA 90073, USA.,David Geffen School of Medicine at UCLA, Los Angeles, Box 951691, Los Angeles, CA 90095, USA
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Fernando SA, Gray TJ, Gottlieb T. Healthcare-acquired infections: prevention strategies. Intern Med J 2018; 47:1341-1351. [PMID: 29224205 DOI: 10.1111/imj.13642] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Revised: 06/01/2017] [Accepted: 06/01/2017] [Indexed: 12/24/2022]
Abstract
Healthcare-acquired infections (HAI) impact on patient care and have cost implications for the Australian healthcare system. The management of HAI is exacerbated by rising rates of antimicrobial resistance (AMR). Health-care workers and a contaminated hospital environment are increasingly implicated in the transmission and persistence of multi-resistant organisms (MRO), as well as other pathogens, such as Clostridium difficile. This has resulted in a timely focus on a range of HAI prevention actions. Core components include antimicrobial stewardship, to reduce overuse and ensure evidence-based antimicrobial use; infection prevention strategies, to control MRO - particularly methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus spp. (VRE) and, more recently, multi-resistant Gram-negative bacteria; enhanced institutional investment in hand hygiene; hospital cleaning and disinfection; and the development of prescribing guidelines and standards of care. AMR surveillance and comparisons of prescribing are useful feedback activities once effectively communicated to end users. Successful implementation of these strategies requires cultural shifts at local hospital level and, to tackle the serious threat posed by AMR, greater co-ordination at a national level. HAI prevention needs to be multi-modal, requires broad healthcare collaboration, and the strong support and accountability of all medical staff.
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Affiliation(s)
- Shelanah A Fernando
- Department of Microbiology & Infectious Diseases, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - Timothy J Gray
- Department of Microbiology & Infectious Diseases, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - Thomas Gottlieb
- Department of Microbiology & Infectious Diseases, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
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Appaneal HJ, Luther MK, Timbrook TT, LaPlante KL, Dosa DM. Facilitators and Barriers to Antibiotic Stewardship: A Qualitative Study of Pharmacists' Perspectives. Hosp Pharm 2018; 54:250-258. [PMID: 31320775 DOI: 10.1177/0018578718781916] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: The Veterans Affairs (VA) is a leader in the implementation and advancement of antibiotic stewardship programs throughout the nation. The Centers for Disease Control and Prevention (CDC) has also led national antibiotic stewardship efforts and has outlined core elements to improve antibiotic use in hospitals, long-term care, and outpatient settings. Many facilities still face challenges to the implementation and maintenance of successful programs, particularly in nonacute care settings. The objective of this study was to identify barriers and facilitators to antibiotic stewardship within the VA medical centers through qualitative interviews with pharmacists. Methods: Eight semi-structured telephone interviews were conducted with pharmacists from 6 VA medical centers within VA New England Healthcare System. Pharmacist respondents were either pharmacy champions (for medical centers with established programs) or pharmacists with responsibilities in making antibiotic recommendations (locations without established programs). All interviews were audio recorded and transcribed verbatim. NVivo 8 was used for data coding and analysis. Results: Pharmacists from all 8 medical centers were contacted for interviews and pharmacists from 6 medical centers agreed to interviews (75% VA New England medical center participation). Three main themes regarding antibiotic stewardship were identified from the interviews with pharmacists. Respondents described the importance of (1) a supportive organizational culture, (2) protected time for antibiotic stewardship, and (3) a cohesive organizational structure in the success of antibiotic stewardship programs. Conclusions: Our findings support the CDC core elements for antibiotic stewardship, in particular the importance of leadership commitment in the creation of a culture that supports antibiotic stewardship and in ensuring staff are given sufficient time for antibiotic stewardship efforts. Although a strong supportive culture has been built, strategies focused on fostering increased protected time for antibiotic stewardship and a cohesive organizational structure may be helpful in advancing and sustaining successful antibiotic stewardship programs that improve patient outcomes.
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Affiliation(s)
- Haley J Appaneal
- Veterans Affairs Medical Center, Providence, RI, USA.,University of Rhode Island, Kingston, RI, USA
| | - Megan K Luther
- Veterans Affairs Medical Center, Providence, RI, USA.,University of Rhode Island, Kingston, RI, USA
| | - Tristan T Timbrook
- Veterans Affairs Medical Center, Providence, RI, USA.,University of Rhode Island, Kingston, RI, USA
| | - Kerry L LaPlante
- Veterans Affairs Medical Center, Providence, RI, USA.,University of Rhode Island, Kingston, RI, USA.,Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - David M Dosa
- Veterans Affairs Medical Center, Providence, RI, USA.,Brown University School of Public Health, Providence, RI, USA
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Manning ML, Septimus EJ, Ashley ESD, Cosgrove SE, Fakih MG, Schweon SJ, Myers FE, Moody JA. Antimicrobial stewardship and infection prevention-leveraging the synergy: A position paper update. Am J Infect Control 2018; 46:364-368. [PMID: 29592832 DOI: 10.1016/j.ajic.2018.01.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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64
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Antimicrobial Stewardship and Infection Prevention—Leveraging the Synergy: A Position Paper Update. Infect Control Hosp Epidemiol 2018; 39:467-472. [DOI: 10.1017/ice.2018.33] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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65
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Perozziello A, Routelous C, Charani E, Truel A, Birgand G, Yazdanpanah Y, Lescure FX, Lucet JC. Experiences and perspectives of implementing antimicrobial stewardship in five French hospitals: a qualitative study. Int J Antimicrob Agents 2018; 51:829-835. [PMID: 29339297 DOI: 10.1016/j.ijantimicag.2018.01.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 11/27/2017] [Accepted: 01/06/2018] [Indexed: 01/21/2023]
Abstract
The aim of this study was to describe current antimicrobial stewardship programmes (ASPs) in France, both at policy level and at local implementation level, and to assess how ASP leaders (ASPL) worked and prioritised their activities. A qualitative study based on face-to-face semi-structured interviews with healthcare professionals responsible for ASPs across five French hospitals was conducted. Five infectious diseases specialists and one microbiologist were interviewed between April-June 2016. Stewards had dedicated time to perform ASP activities in two university-affiliated hospitals, whilst in the other hospitals (one university, one general and one semi-private), ASPLs had to balance these activities with clinical practice. Consequently, they had to adapt interventions according to their resources (IT or human). Responding to colleagues' consultation requests formed baseline work. Systematic and pro-active measures allowed for provision of unsolicited counselling, whilst direct counselling on wards required appropriate staffing. ASPLs aimed at increasing clinicians' ability to prescribe adequately and awareness of the unintended consequences of inappropriate use of antibiotics. Thus, persuasive, e.g. education, measures were preferred to coercive ones. ASPLs faced several challenges in implementing the ASP: overcoming physicians' or units' reluctance; and balancing the influence of medical hierarchy and professional boundaries. Beyond resources constraints, ASPLs' conceptions of their work, as well as contextual and cultural aspects, led them to adopt a persuasive and collaborative approach of counselling. This is the first qualitative study regarding ASPs in France exploring stewards' experiences and points of view.
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Affiliation(s)
- Anne Perozziello
- IAME, UMR 1137, DeSCID Team, Université Paris Diderot, Sorbonne Paris Cité, Paris, France.
| | - Christelle Routelous
- Institut du Management/EA 7348 MOS Management des organisations en santé, Ecole des hautes études en santé publique, EHESP, Rennes Sorbonne Paris Cité, Paris, France
| | - Esmita Charani
- NIHR Health Protection Research Unit in Antimicrobial Resistance and Healthcare Associated Infection, Imperial College London, Department of Medicine, London, UK
| | - Alice Truel
- IAME, UMR 1137, DeSCID Team, Université Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Gabriel Birgand
- Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
| | - Yazdan Yazdanpanah
- IAME, UMR 1137, DeSCID Team, Université Paris Diderot, Sorbonne Paris Cité, Paris, France; Service de Maladies Infectieuses et Tropicales, Hôpital Bichat-Claude Bernard, AP-HP, Paris, France
| | - François-Xavier Lescure
- IAME, UMR 1137, DeSCID Team, Université Paris Diderot, Sorbonne Paris Cité, Paris, France; Service de Maladies Infectieuses et Tropicales, Hôpital Bichat-Claude Bernard, AP-HP, Paris, France
| | - Jean-Christophe Lucet
- IAME, UMR 1137, DeSCID Team, Université Paris Diderot, Sorbonne Paris Cité, Paris, France; Unité d'Hygiène et de Lutte contre les Infections Nosocomiales (UHLIN), Hôpital Bichat-Claude Bernard, AP-HP, Paris, France
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Kapadia SN, Abramson EL, Carter EJ, Loo AS, Kaushal R, Calfee DP, Simon MS. The Expanding Role of Antimicrobial Stewardship Programs in Hospitals in the United States: Lessons Learned from a Multisite Qualitative Study. Jt Comm J Qual Patient Saf 2018; 44:68-74. [PMID: 29389462 DOI: 10.1016/j.jcjq.2017.07.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 07/21/2017] [Accepted: 07/31/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Misuse of antibiotics can lead to the development of antibiotic resistance, which adversely affects morbidity, mortality, length of stay, and cost. To combat the threat of antimicrobial resistance, The Joint Commission and the Centers for Medicare & Medicaid Services have initiated or proposed requirements for hospitals to have antimicrobial stewardship programs (ASPs), but implementation remains challenging. A key-informant interview study was conducted to describe the characteristics and innovative strategies of leading ASPs. METHODS Semistructured interviews were conducted with 12 program leaders at four ASPs in the United States, chosen by purposive sampling on the basis of national reputation, scholarship, and geography. Questions focused on ASP implementation, program structure, strengths, weaknesses, lessons learned, and future directions. Content analysis was used to identify dominant themes. RESULTS Three major themes were identified. The first was evolution of ASPs from a top-down structure to a more diffuse approach involving unit-based pharmacists, multidisciplinary staff, and shared responsibility for antimicrobial prescribing under the ASPs' leadership. The second theme was integration of information technology (IT) systems, which enabled real-time interventions to optimize antimicrobial therapy and patient management. The third was barriers to technology integration, including limited resources for data analysis and poor interoperability between software systems. CONCLUSION The study provides valuable insights on program implementation at a sample of leading ASPs across the United States. These ASPs used expansion of personnel to amplify the ASP's impact and integrated IT resources into daily work flow to improve efficiency. These findings can be used to guide implementation at other hospitals and aid in future policy development.
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Willis ZI, Gillon J, Xu M, Slaughter JC, Di Pentima MC. Reducing Antimicrobial Use in an Academic Pediatric Institution: Evaluation of the Effectiveness of a Prospective Audit With Real-Time Feedback. J Pediatric Infect Dis Soc 2017; 6:339-345. [PMID: 28339590 PMCID: PMC5907874 DOI: 10.1093/jpids/piw054] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 08/24/2016] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Antimicrobial use is decreasing across freestanding children's hospitals, predominantly in institutions with antimicrobial stewardship programs (ASPs) in place. A highly effective ASP should effect a greater decrease in use than predicted by existing trends. Antimicrobial stewardship programs depend on clinician adherence to program recommendations, but little is known about factors associated with adherence. METHODS Parenteral antimicrobial-use data for our institution and 43 additional freestanding children's hospitals were obtained and normalized for patient census. Segmental linear regression was used to compare rates of change of parenteral antimicrobial use before and after ASP implementation. Time-series models were developed to predict use in the absence of intervention. The odds of adherence to ASP recommendations were determined based on provider characteristics and recommendation type. RESULTS In the 38 months before ASP implementation, parenteral antimicrobial use was decreasing at our hospital by 3.7%/year, similar to the 3.4%/year found across children's hospitals. The rate of change after implementation of the ASP at our hospital was 11.1%/year, compared to 5.6%/year for other hospitals over the same period. Of 643 interventions, teams adhered with recommendations in 495 cases (77.0%). According to adjusted analysis, primary service was not associated with adherence (P = .356). There was an association between adherence and the role of the clinician receiving a recommendation (P = .009) and the recommendation type (P = .009). CONCLUSIONS Understanding factors associated with adherence to ASP recommendations can help those who administer such programs to strategize interventions for maximizing efficacy. Our findings reveal the value of a formal ASP in reducing use when controlling for secular trends.
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Affiliation(s)
| | - Jessica Gillon
- Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Meng Xu
- Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - James C Slaughter
- Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - M Cecilia Di Pentima
- Department of Pediatrics, Goryeb Children's Hospital, Morristown, New Jersey,Corresponding Author: M. Cecilia Di Pentima, MD, MPH, FAAP, Pediatric Infectious Diseases, Goryeb Children's Hospital, Atlantic Health System, 100 Madison Ave (#29B), Morristown, NJ 07962–1956. E-mail:
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Cantey JB, Vora N, Sunkara M. Prevalence, Characteristics, and Perception of Nursery Antibiotic Stewardship Coverage in the United States. J Pediatric Infect Dis Soc 2017; 6:e30-e35. [PMID: 27422868 DOI: 10.1093/jpids/piw040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 06/13/2016] [Indexed: 11/15/2022]
Abstract
BACKGROUND Prolonged or unnecessary antibiotic use is associated with adverse outcomes in infants. Antibiotic stewardship programs (ASPs) aim to prevent these adverse outcomes and optimize antibiotic prescribing. However, data evaluating ASP coverage of nurseries are limited. The objectives of this study were to describe the characteristics of nurseries with and without ASP coverage and to determine perceptions of and barriers to nursery ASP coverage. METHODS The 2014 American Hospital Association annual survey was used to randomly select a level III neonatal intensive care unit from all 50 states. A level I and level II nursery from the same city as the level III nursery were then randomly selected. Hospital, nursery, and ASP characteristics were collected. Nursery and ASP providers (pharmacists or infectious disease providers) were interviewed using a semistructured template. Transcribed interviews were analyzed for themes. RESULTS One hundred forty-six centers responded; 104 (71%) provided nursery ASP coverage. In multivariate analysis, level of nursery, university affiliation, and number of full-time equivalent ASP staff were the main predictors of nursery ASP coverage. Several themes were identified from interviews: unwanted coverage, unnecessary coverage, jurisdiction issues, need for communication, and a focus on outcomes. Most providers had a favorable view of nursery ASP coverage. CONCLUSIONS Larger, higher-acuity nurseries in university-affiliated hospitals are more likely to have ASP coverage. Low ASP staffing and a perceived lack of importance were frequently cited as barriers to nursery coverage. Most nursery ASP coverage is viewed favorably by providers, but nursery providers regard it as less important than ASP providers.
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Affiliation(s)
- Joseph B Cantey
- Department of Pediatrics, Divisions of Neonatal/Perinatal Medicine.,Pediatric Infectious Diseases, Texas A&M Health Science Center, Temple
| | - Niraj Vora
- Department of Pediatrics, Divisions of Neonatal/Perinatal Medicine
| | - Mridula Sunkara
- Department of Pediatrics, Divisions of Neonatal/Perinatal Medicine
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Reducing Second Gram-Negative Antibiotic Therapy on Pediatric Oncology and Hematopoietic Stem Cell Transplantation Services. Infect Control Hosp Epidemiol 2017; 38:1039-1047. [PMID: 28758610 DOI: 10.1017/ice.2017.118] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate interventions to reduce avoidable antibiotic use on pediatric oncology and hematopoietic stem cell transplantation (HSCT) services. DESIGN Interrupted time series. SETTING Academic pediatric hospital with separate oncology and HSCT services. PARTICIPANTS Children admitted to the services during baseline (October 2011-August 2013) and 2 intervention periods, September 2013-June 2015 and July 2015-June 2016, including 1,525 oncology hospitalizations and 301 HSCT hospitalizations. INTERVENTION In phase 1, we completed an update of the institutional febrile neutropenia (FN) guideline for the pediatric oncology service, recommending first-line β-lactam monotherapy rather than routine use of 2 gram-negative agents. Phase 2 included updating the HSCT service FN guideline and engagement with a new pediatric antimicrobial stewardship program. The use of target antibiotics (tobramycin and ciprofloxacin) was measured in days of therapy per 1,000 patient days collected from administrative data. Intervention effects were evaluated using interrupted time series with segmented regression. RESULTS Phase 1 had mixed effects-long-term reduction in tobramycin use (97% below projected at 18 months) but rebound with increasing slope in ciprofloxacin use (+18% per month). Following phase 2, tobramycin and ciprofloxacin use on the oncology service were both 99% below projected levels at 12 months. On the HSCT service, tobramycin use was 99% below the projected level and ciprofloxacin use was 96% below the projected level at 12 months. CONCLUSIONS Locally adapted guidelines can facilitate practice changes in oncology and HSCT settings. More comprehensive and ongoing interventions, including follow-up education, feedback, and engagement of companion services may be needed to sustain changes. Infect Control Hosp Epidemiol 2017;38:1039-1047.
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Molloy L, McGrath E, Thomas R, Kaye KS, Rybak MJ. Acceptance of Pharmacist-Driven Antimicrobial Stewardship Recommendations With Differing Levels of Physician Involvement in a Children's Hospital. Clin Pediatr (Phila) 2017; 56:744-751. [PMID: 27872355 DOI: 10.1177/0009922816678598] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
This prospective interventional study assessed whether a pharmacist-physician team in a setting where physician support is not provided for daily antimicrobial stewardship (AS) activities would improve later acceptance of pharmacist recommendations once multidisciplinary efforts stopped and the pharmacist again worked alone. This was measured by AS recommendation acceptance rate during 3 study phases wherein AS recommendations were provided by a pharmacist alone (Phase 1), a pharmacist and a physician together (Phase 2), and then a pharmacist alone again (Phase 3). Recommendations were well accepted across all study phases with no differences in recommendation appropriateness or patient clinical outcomes. Prescribers were significantly ( P = .045) more likely to accept recommendations to de-escalate treatment during Phase 3 than during Phase 1. Independently pharmacist-driven AS efforts were generally successful, and recommendations for antimicrobial de-escalation were better accepted after the involvement of an infectious diseases physician.
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Affiliation(s)
- Leah Molloy
- 1 Children's Hospital of Michigan, Detroit, MI, USA.,3 Detroit Medical Center, Detroit, MI, USA
| | - Eric McGrath
- 1 Children's Hospital of Michigan, Detroit, MI, USA.,2 Wayne State University, Detroit, MI, USA.,3 Detroit Medical Center, Detroit, MI, USA
| | | | - Keith S Kaye
- 2 Wayne State University, Detroit, MI, USA.,3 Detroit Medical Center, Detroit, MI, USA
| | - Michael J Rybak
- 2 Wayne State University, Detroit, MI, USA.,3 Detroit Medical Center, Detroit, MI, USA
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Van Parys J, Stevens MP, Moczygemba LR, Pakyz AL. Antimicrobial Stewardship Program Members' Perspectives on Program Goals and National Metrics. Clin Ther 2016; 38:1914-9. [PMID: 27392717 DOI: 10.1016/j.clinthera.2016.06.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 05/27/2016] [Accepted: 06/08/2016] [Indexed: 01/14/2023]
Abstract
PURPOSE This study compares antimicrobial stewardship program (ASP)-stated goals and outcomes collected as well as opinions regarding national metric establishment. METHODS Twenty-one ASP members underwent telephone interviews answering open-ended questions about ASP goals, outcomes collected, and opinions about national metrics. Content analysis was used to code responses into predefined ASP-metric categories. FINDINGS The most common ASP goal was antimicrobial appropriateness (76%), outcomes tracked were use and microbial outcomes (both 71%), and desired national metric was use (67%). IMPLICATIONS Stated-goals, outcomes tracked, and opinions regarding national metric establishment did not fully align. With ASP-related regulations looming, it is important that alignment is increased.
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Affiliation(s)
- Jacob Van Parys
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, Virginia
| | - Michael P Stevens
- Division of Infectious Diseases, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Leticia R Moczygemba
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, Virginia
| | - Amy L Pakyz
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, Virginia
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Barlam TF, Cosgrove SE, Abbo LM, MacDougall C, Schuetz AN, Septimus EJ, Srinivasan A, Dellit TH, Falck-Ytter YT, Fishman NO, Hamilton CW, Jenkins TC, Lipsett PA, Malani PN, May LS, Moran GJ, Neuhauser MM, Newland JG, Ohl CA, Samore MH, Seo SK, Trivedi KK. Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis 2016; 62:e51-77. [PMID: 27080992 PMCID: PMC5006285 DOI: 10.1093/cid/ciw118] [Citation(s) in RCA: 1795] [Impact Index Per Article: 224.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 02/23/2016] [Indexed: 12/11/2022] Open
Abstract
Evidence-based guidelines for implementation and measurement of antibiotic stewardship interventions in inpatient populations including long-term care were prepared by a multidisciplinary expert panel of the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. The panel included clinicians and investigators representing internal medicine, emergency medicine, microbiology, critical care, surgery, epidemiology, pharmacy, and adult and pediatric infectious diseases specialties. These recommendations address the best approaches for antibiotic stewardship programs to influence the optimal use of antibiotics.
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Affiliation(s)
- Tamar F Barlam
- Section of Infectious Diseases, Boston University School of Medicine, Boston, Massachusetts
| | - Sara E Cosgrove
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Lilian M Abbo
- Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, Florida
| | - Conan MacDougall
- Department of Clinical Pharmacy, School of Pharmacy, University of California, San Francisco
| | - Audrey N Schuetz
- Department of Medicine, Weill Cornell Medical Center/New York-Presbyterian Hospital, New York, New York
| | - Edward J Septimus
- Department of Internal Medicine, Texas A&M Health Science Center College of Medicine, Houston
| | - Arjun Srinivasan
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Timothy H Dellit
- Division of Allergy and Infectious Diseases, University of Washington School of Medicine, Seattle
| | - Yngve T Falck-Ytter
- Department of Medicine, Case Western Reserve University and Veterans Affairs Medical Center, Cleveland, Ohio
| | - Neil O Fishman
- Department of Medicine, University of Pennsylvania Health System, Philadelphia
| | | | | | - Pamela A Lipsett
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University Schools of Medicine and Nursing, Baltimore, Maryland
| | - Preeti N Malani
- Division of Infectious Diseases, University of Michigan Health System, Ann Arbor
| | - Larissa S May
- Department of Emergency Medicine, University of California, Davis
| | - Gregory J Moran
- Department of Emergency Medicine, David Geffen School of Medicine, University of California, Los Angeles Medical Center, Sylmar
| | | | - Jason G Newland
- Department of Pediatrics, Washington University School of Medicine in St. Louis, Missouri
| | - Christopher A Ohl
- Section on Infectious Diseases, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Matthew H Samore
- Department of Veterans Affairs and University of Utah, Salt Lake City
| | - Susan K Seo
- Infectious Diseases, Memorial Sloan Kettering Cancer Center, New York, New York
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Characteristics of Antimicrobial Stewardship Programs at Veterans Affairs Hospitals: Results of a Nationwide Survey. Infect Control Hosp Epidemiol 2016; 37:647-54. [PMID: 26905338 DOI: 10.1017/ice.2016.26] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Antimicrobial stewardship programs (ASPs) are variably implemented. OBJECTIVE To characterize variations of antimicrobial stewardship structure and practices across all inpatient Veterans Affairs facilities in 2012 and correlate key characteristics with antimicrobial usage. DESIGN A web-based survey regarding stewardship activities was administered to each facility's designated contact. Bivariate associations between facility characteristics and inpatient antimicrobial use during 2012 were determined. SETTING Total of 130 Veterans Affairs facilities with inpatient services. RESULTS Of 130 responding facilities, 29 (22%) had a formal policy establishing an ASP, and 12 (9%) had an approved ASP business plan. Antimicrobial stewardship teams were present in 49 facilities (38%); 34 teams included a clinical pharmacist with formal infectious diseases (ID) training. Stewardship activities varied across facilities, including development of yearly antibiograms (122 [94%]), formulary restrictions (120 [92%]), stop orders for antimicrobial duration (98 [75%]), and written clinical pathways for specific conditions (96 [74%]). Decreased antimicrobial usage was associated with having at least 1 full-time ID physician (P=.03), an ID fellowship program (P=.003), and a clinical pharmacist with formal ID training (P=.006) as well as frequency of systematic patient-level reviews of antimicrobial use (P=.01) and having a policy to address antimicrobial use in the context of Clostridium difficile infection (P=.01). Stop orders for antimicrobial duration were associated with increased use (P=.03). CONCLUSIONS ASP-related activities varied considerably. Decreased antibiotic use appeared related to ID presence and certain select practices. Further statistical assessments may help optimize antimicrobial practices. Infect Control Hosp Epidemiol 2016;37:647-654.
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Akpan MR, Ahmad R, Shebl NA, Ashiru-Oredope D. A Review of Quality Measures for Assessing the Impact of Antimicrobial Stewardship Programs in Hospitals. Antibiotics (Basel) 2016; 5:E5. [PMID: 27025520 PMCID: PMC4810407 DOI: 10.3390/antibiotics5010005] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 12/04/2015] [Accepted: 01/04/2016] [Indexed: 01/08/2023] Open
Abstract
The growing problem of antimicrobial resistance (AMR) has led to calls for antimicrobial stewardship programs (ASP) to control antibiotic use in healthcare settings. Key strategies include prospective audit with feedback and intervention, and formulary restriction and preauthorization. Education, guidelines, clinical pathways, de-escalation, and intravenous to oral conversion are also part of some programs. Impact and quality of ASP can be assessed using process or outcome measures. Outcome measures are categorized as microbiological, patient or financial outcomes. The objective of this review was to provide an overview of quality measures for assessing ASP and the reported impact of ASP in peer-reviewed studies, focusing particularly on patient outcomes. A literature search of papers published in English between 1990 and June 2015 was conducted in five databases using a combination of search terms. Primary studies of any design were included. A total of 63 studies were included in this review. Four studies defined quality metrics for evaluating ASP. Twenty-one studies assessed the impact of ASP on antimicrobial utilization and cost, 25 studies evaluated impact on resistance patterns and/or rate of Clostridium difficile infection (CDI). Thirteen studies assessed impact on patient outcomes including mortality, length of stay (LOS) and readmission rates. Six of these 13 studies reported non-significant difference in mortality between pre- and post-ASP intervention, and five reported reductions in mortality rate. On LOS, six studies reported shorter LOS post intervention; a significant reduction was reported in one of these studies. Of note, this latter study reported significantly (p < 0.001) higher unplanned readmissions related to infections post-ASP. Patient outcomes need to be a key component of ASP evaluation. The choice of metrics is influenced by data and resource availability. Controlling for confounders must be considered in the design of evaluation studies to adequately capture the impact of ASP and it is important for unintended consequences to be considered. This review provides a starting point toward compiling standard outcome metrics for assessing ASP.
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Affiliation(s)
- Mary Richard Akpan
- Department of Pharmacy, Pharmacology and Postgraduate Medicine, University of Hertfordshire, Hatfield, AL10 9AB, UK.
| | - Raheelah Ahmad
- NIHR Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance at Imperial College London, Hammersmith Campus, Du Cane Road, London, W12 0NN, UK.
| | - Nada Atef Shebl
- Department of Pharmacy, Pharmacology and Postgraduate Medicine, University of Hertfordshire, Hatfield, AL10 9AB, UK.
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Loh JA, Darby JD, Daffy JR, Moore CL, Battye MJ, Poy Lorenzo YS, Stanley PA. Implementation of an antimicrobial stewardship program in an Australian metropolitan private hospital: lessons learned. ACTA ACUST UNITED AC 2015. [DOI: 10.1071/hi15015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Introduction: From science to implementation: The Agency for Healthcare Research and Quality's program to prevent healthcare-associated infections-results and lessons learned. Am J Infect Control 2014; 42:S189-90. [PMID: 25239708 DOI: 10.1016/j.ajic.2014.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Accepted: 07/03/2014] [Indexed: 11/23/2022]
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