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Cresswell K, Hinder S, Sheikh A, Watson N, Price D, Heed A, Pontefract SK, Coleman J, Beggs J, Chuter A, Slee A, Williams R. Complex Hospital-Based Electronic Prescribing-Based Intervention to Support Antimicrobial Stewardship: Qualitative Study. JMIR Form Res 2024; 8:e54458. [PMID: 39059001 DOI: 10.2196/54458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 03/23/2024] [Accepted: 03/28/2024] [Indexed: 07/28/2024] Open
Abstract
BACKGROUND Antimicrobial resistance (AMR) represents a growing concern for public health. OBJECTIVE We sought to explore the challenges associated with development and implementation of a complex intervention designed to improve AMS in hospitals. METHODS We conducted a qualitative evaluation of a complex AMS intervention with educational, behavioral, and technological components in 5 wards of an English hospital. At 2 weeks and 7 weeks after initiating the intervention, we interviewed 25 users of the intervention, including senior and junior prescribers, a senior nurse, a pharmacist, and a microbiologist. Topics discussed included perceived impacts of different elements of the intervention and facilitators and barriers to effective use. Interviews were supplemented by 2 observations of ward rounds to gain insights into AMS practices. Data were audio-recorded, transcribed, and inductively and deductively analyzed thematically using NVivo12. RESULTS Tracing the adoption and impact of the various components of the intervention was difficult, as it had been introduced into a setting with competing pressures. These particularly affected behavioral and educational components (eg, training, awareness-building activities), which were often delivered ad hoc. We found that the participatory intervention design had addressed typical use cases but had not catered for edge cases that only became visible when the intervention was delivered in real-world settings (eg, variations in prescribing workflows across different specialties and conditions). CONCLUSIONS Effective user-focused design of complex interventions to promote AMS can support acceptance and use. However, not all requirements and potential barriers to use can be fully anticipated or tested in advance of full implementation in real-world settings.
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Affiliation(s)
| | - Susan Hinder
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Aziz Sheikh
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Neil Watson
- Newcastle upon Tyne Hospitals National Health Service Foundation Trust, Newcastle, United Kingdom
| | - David Price
- Newcastle upon Tyne Hospitals National Health Service Foundation Trust, Newcastle, United Kingdom
| | - Andrew Heed
- Newcastle upon Tyne Hospitals National Health Service Foundation Trust, Newcastle, United Kingdom
| | | | - Jamie Coleman
- Institute of Clinical Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Jillian Beggs
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Antony Chuter
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Ann Slee
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Robin Williams
- Institute for the Study of Science, Technology and Innovation, The University of Edinburgh, Edinburgh, United Kingdom
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Del Fabro G, Venturini S, Avolio M, Basaglia G, Callegari A, Bramuzzo I, Basso B, Zanusso C, Rizzo A, Tonutti G, Chittaro M, Fiappo E, Tonizzo M, Crapis M. Time is running out. No excuses to delay implementation of antimicrobial stewardship programmes: impact, sustainability, resilience and efficiency through an interrupted time series analysis (2017-2022). JAC Antimicrob Resist 2024; 6:dlae072. [PMID: 38752207 PMCID: PMC11094472 DOI: 10.1093/jacamr/dlae072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Accepted: 04/20/2024] [Indexed: 05/18/2024] Open
Abstract
Introduction The WHO declared antimicrobial resistance (AMR) a significant concern in 2014, sparking initiatives to ensure responsible antibiotic use. In human medicine, Antimicrobial Stewardship Programmes (ASPs) in hospitals play a pivotal role in combating AMR. Although evidence supports the effectiveness of ASPs in optimizing antimicrobial use, often the lack of resources becomes an excuse to limit their dissemination and use. This paper provides a comprehensive report on a 6-year analysis of an ASP implemented in a healthcare region in north-east Italy. Methods A retrospective data collection was conducted to assess the programme's impact on antibiotic consumption expressed as DDDs/100 patient-days, its sustainability over time, resilience during the COVID-19 pandemic and the efficiency of the ASP (relationship between workload and human resources). Results A substantial overall reduction in antibiotic consumption (-14%), particularly in fluoroquinolones (-64%) and carbapenems (-68%), was demonstrated, showcasing the programme's impact. Sustainability was confirmed through enduring trends in antibiotic consumption and ecological analysis over time. The ASP demonstrates resilience by maintaining positive trends even amid the challenging COVID-19 pandemic. Efficiency was underscored by an increase in on-site consultations despite consistent human resources until 2021. Conclusions This study offers insights into the prolonged success of a resource-efficient ASP, emphasizing the crucial role of long-term commitment in fostering responsible antibiotic use in the context of global health challenges such as AMR.
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Affiliation(s)
- Giovanni Del Fabro
- Department of Infectious Diseases, ASFO ‘Santa Maria degli Angeli’ Hospital of Pordenone, via Montereale 24, Pordenone 33170, Italy
| | - Sergio Venturini
- Department of Infectious Diseases, ASFO ‘Santa Maria degli Angeli’ Hospital of Pordenone, via Montereale 24, Pordenone 33170, Italy
| | - Manuela Avolio
- Department of Microbiology, ASFO ‘Santa Maria degli Angeli’ Hospital of Pordenone, Pordenone, Italy
| | - Giancarlo Basaglia
- Department of Microbiology, ASFO ‘Santa Maria degli Angeli’ Hospital of Pordenone, Pordenone, Italy
| | - Astrid Callegari
- Department of Infectious Diseases, ASFO ‘Santa Maria degli Angeli’ Hospital of Pordenone, via Montereale 24, Pordenone 33170, Italy
| | - Igor Bramuzzo
- Department of Infectious Diseases, ASFO ‘Santa Maria degli Angeli’ Hospital of Pordenone, via Montereale 24, Pordenone 33170, Italy
| | - Barbara Basso
- Hospital Pharmacy, ASFO ‘Santa Maria degli Angeli’ Hospital of Pordenone, Pordenone, Italy
| | - Chiara Zanusso
- Hospital Pharmacy, ASFO ‘Santa Maria degli Angeli’ Hospital of Pordenone, Pordenone, Italy
| | - Anna Rizzo
- Hospital Pharmacy, ASFO ‘Santa Maria degli Angeli’ Hospital of Pordenone, Pordenone, Italy
| | - Giuseppe Tonutti
- Hospital Health Direction, ASFO ‘Santa Maria degli Angeli’ Hospital of Pordenone, Pordenone, Italy
| | - Michele Chittaro
- Hospital Health Direction, ASFO ‘Santa Maria degli Angeli’ Hospital of Pordenone, Pordenone, Italy
| | - Eva Fiappo
- Hospital Health Direction, ASFO ‘Santa Maria degli Angeli’ Hospital of Pordenone, Pordenone, Italy
| | - Maurizio Tonizzo
- Department of Internal Medicine, ASFO ‘Santa Maria degli Angeli’ Hospital of Pordenone, Pordenone, Italy
| | - Massimo Crapis
- Department of Infectious Diseases, ASFO ‘Santa Maria degli Angeli’ Hospital of Pordenone, via Montereale 24, Pordenone 33170, Italy
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Alves J, Prendki V, Chedid M, Yahav D, Bosetti D, Rello J. Challenges of antimicrobial stewardship among older adults. Eur J Intern Med 2024; 124:5-13. [PMID: 38360513 DOI: 10.1016/j.ejim.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 01/06/2024] [Accepted: 01/15/2024] [Indexed: 02/17/2024]
Abstract
Older adults hospitalized in internal medicine wards or long-term care facilities (LTCF) are progressively increasing. Older adults with multimorbidity are more susceptible to infections, as well as to more vulnerable to adverse effects (and interactions) of antibiotics, resulting in a need for effective and safer strategies for antimicrobial stewardship (ASM), both in hospitalization wards and long-term care facilities. Studies on antimicrobial stewardship in older patients are scarce and guidelines are required. Given the peculiarities of the optimization of antimicrobial prescription in individual older adults for common infections, tactics to overcome barriers need an update. The use of rapid diagnosis tests, biomarkers, de-escalation and switching from intravenous to oral/subcutaneous therapy strategies are examples of successful AMS interventions. AMS interventions are associated with reduced side effects, lower mortality, shorter hospital stays, and reduced costs. The proposed AMS framework in LTCF should focus on five domains: strategic vision, team, interventions, patient-centred care and awareness. Internists can partner with geriatrists, pharmacists and infectious disease specialists to address barriers and to improve patient care.
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Affiliation(s)
- Joana Alves
- Infectious Diseases Specialist, Head of Local Unit of the Program for Prevention and Control of Infection and Antimicrobial Resistance, Hospital de Braga, Portugal.
| | - Virginie Prendki
- Department of Internal Medicine for the Aged, Department of Rehabilitation and Geriatrics, Geneva University Hospitals, Geneva, Switzerland; Department of Infectious Disease, Geneva University Hospital, Switzerland
| | - Marie Chedid
- Department of Infectious Disease, Geneva University Hospital, Switzerland
| | - Dafna Yahav
- Infectious Diseases Unit, Sheba Medical Centre, Ramat Gan, Israel
| | - Davide Bosetti
- Department of Infectious Disease, Geneva University Hospital, Switzerland; Infection Control Programme and WHO Collaborating Centre for Infection Prevention and Control and Antimicrobial Resistance, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Jordi Rello
- Medicine Department, Universitat Internacional de Catalunya, Spain; Clinical Research Pneumonia and Sepsis (CRIPS) Research Group-Vall d'Hebrón Institute Research (VHIR), Barcelona, Spain; Formation, Recherche, Evaluation (FOREVA), CHU Nîmes, Nîmes, France
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Sangji NF, Dougherty JM, Tignanelli CJ, Maqsood HA, Cain-Nielsen AH, Oliphant BW, Hemmila MR. Calculation and Feedback of Risk-Adjusted Antibiotic Days as a Process Measure in a Statewide Trauma Collaborative. Am Surg 2024:31348241256070. [PMID: 38770751 DOI: 10.1177/00031348241256070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
BACKGROUND Optimization of antibiotic stewardship requires determining appropriate antibiotic treatment and duration of use. Our current method of identifying infectious complications alone does not attempt to measure the resources actually utilized to treat infections in patients. We sought to develop a method accounting for treatment of infections and length of antibiotic administration to allow benchmarking of trauma hospitals with regard to days of antibiotic use. METHODS Using trauma quality collaborative data from 35 American College of Surgeons (ACS)-verified level I and level II trauma centers between November 1, 2020, and January 31, 2023, a two-part model was created to account for (1) the odds of any antibiotic use, using logistic regression; and (2) the duration of usage, using negative binomial distribution. We adjusted for injury severity, presence/type of infection (eg, ventilator-acquired pneumonia), infectious complications, and comorbid conditions. We performed observed-to-expected adjustments to calculate each center's risk-adjusted antibiotic days, bootstrapped Observed/Expected (O/E) ratios to create confidence intervals, and flagged potential high or low outliers as hospitals whose confidence intervals lay above or below the overall mean. RESULTS The mean antibiotic treatment days was 1.98°days with a total of 88,403 treatment days. A wide variation existed in risk-adjusted antibiotic treatment days (.76°days to 2.69°days). Several hospitals were identified as low (9 centers) or high (6 centers) outliers. CONCLUSION There exists a wide variation in the duration of risk-adjusted antibiotic use amongst trauma centers. Further study is needed to address the underlying cause of variation and for improved antibiotic stewardship.
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Affiliation(s)
- Naveen F Sangji
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Jacob M Dougherty
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Christopher J Tignanelli
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA
- Center for Learning Health Systems Science, University of Minnesota, Minneapolis, MN, USA
| | - Hannan A Maqsood
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Anne H Cain-Nielsen
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Bryant W Oliphant
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Mark R Hemmila
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
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Kuijpers SME, van Haeringen KJ, Groot T, Sigaloff KCE, van Hest RM, Prins JM, Schade RP. Identifying excessive length of antibiotic treatment duration for hospital-acquired infections: a semi-automated approach to support antimicrobial stewardship. Antimicrob Resist Infect Control 2024; 13:52. [PMID: 38764096 PMCID: PMC11103818 DOI: 10.1186/s13756-024-01406-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 05/01/2024] [Indexed: 05/21/2024] Open
Abstract
BACKGROUND Avoiding excessive antibiotic treatment duration is a fundamental goal in antimicrobial stewardship. Manual collection of data is a time-consuming process, but a semi-automated approach for data extraction has been shown feasible for community-acquired infections (CAI). Extraction of data however may be more challenging in hospital-acquired infections (HAI). The aim of this study is to explore whether semi-automated data extraction of treatment duration is also feasible and accurate for HAI. METHODS Data from a university-affiliated hospital over the period 1-6-2020 until 1-6-2022 was used for this study. From the Electronic Health Record, raw data on prescriptions, registered indications and admissions was extracted and processed to define treatment courses. In addition, clinical notes including prescription instructions were obtained for the purpose of validation. The derived treatment course was compared to the registered indication and the actual length of treatment (LOT) in the clinical notes in a random sample of 5.7% of treatment courses, to assess the accuracy of the data for both CAI and HAI. RESULTS Included were 10.564 treatment courses of which 73.1% were CAI and 26.8% HAI. The registered indication matched the diagnosis as recorded in the clinical notes in 79% of treatment courses (79.2% CAI, 78.5% HAI). Higher error rates were seen in urinary tract infections (UTIs) (29.0%) and respiratory tract infections (RTIs) (20.5%) compared to intra-abdominal infections (7.4%), or skin or soft tissue infections (11.1%), mainly due to incorrect specification of the type of UTI or RTI. The LOT was accurately extracted in 98.5% of courses (CAI 98.2%, HAI 99.3%) when compared to prescriptions in the EHR. In 21% of cases however the LOT did not match with the clinical notes, mainly if patients received treatment from other health care providers preceding or following the present course. CONCLUSION Semi-automatic data extraction can yield reliable information about the indication and LOT in treatment courses of hospitalized patients, for both HAI and CAI. This can provide stewardship programs with a surveillance tool for all in-hospital treated infections, which can be used to achieve stewardship goals.
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Affiliation(s)
- Suzanne M E Kuijpers
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Koen J van Haeringen
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Thomas Groot
- Department of Medical Microbiology and Infection Prevention, Amsterdam UMC, University of Amsterdam, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Kim C E Sigaloff
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Reinier M van Hest
- Department of Clinical Pharmacology, Department of Hospital Pharmacy, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jan M Prins
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Rogier P Schade
- Department of Medical Microbiology and Infection Prevention, Amsterdam UMC, University of Amsterdam, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.
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Talkhan H, Stewart D, McIntosh T, Ziglam H, Abdulrouf PV, Al-Hail M, Diab M, Cunningham S. Exploring determinants of antimicrobial prescribing behaviour using the Theoretical Domains Framework. Res Social Adm Pharm 2024; 20:401-410. [PMID: 38320948 DOI: 10.1016/j.sapharm.2023.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 12/19/2023] [Accepted: 12/21/2023] [Indexed: 02/08/2024]
Abstract
BACKGROUND Few theoretically-based, qualitative studies have explored determinants of antimicrobial prescribing behaviour in hospitals. Understanding these can promote successful development and implementation of behaviour change interventions (BCIs). OBJECTIVE (s): To use the Theoretical Domains Framework (TDF) to explore determinants of clinicians' antimicrobial prescribing behaviour, identifying barriers (i.e., impediments) and facilitators to appropriate antimicrobial practice. METHODS Semi-structured interviews with purposively-sampled doctors and pharmacists with a wide range of specialties and expertise in Hamad Medical Corporation hospitals in Qatar. Interviews based on previous quantitative research and the TDF were audio-recorded, transcribed and independently analysed by two researchers using the TDF as an initial coding framework. RESULTS Data saturation was achieved after interviewing eight doctors and eight pharmacists. Inter-related determinants of antimicrobial prescribing behaviour linked to ten TDF domains were identified as barriers and facilitators that may contribute to inappropriate or appropriate antimicrobial prescribing. The main barriers identified were around hospital guidelines and electronic system deficiencies (environmental context and resources); knowledge gaps relating to guidelines and appropriate prescribing (knowledge); restricted roles/responsibilities of microbiologists and pharmacists (professional role and identity); challenging antimicrobial prescribing decisions (memory, attention and decision processes); and professional hierarchies and poor multidisciplinary teamworking (social influences). Key facilitators included guidelines compliance (goals and intentions), and participants' beliefs about the consequences of appropriate or inappropriate prescribing. Further education and training, and some changes to guidelines including their accessibility were also considered essential. CONCLUSIONS Antimicrobial prescribing behaviour in hospitals is a complex process influenced by a broad range of determinants including specific barriers and facilitators. The in-depth understanding of this complexity provided by this work may support the development of an effective BCI to promote appropriate antimicrobial stewardship.
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Affiliation(s)
- Hend Talkhan
- School of Pharmacy and Life Sciences, Robert Gordon University, UK.
| | - Derek Stewart
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar.
| | - Trudi McIntosh
- School of Pharmacy and Life Sciences, Robert Gordon University, UK.
| | - Hisham Ziglam
- Infectious Diseases Department, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar.
| | | | - Moza Al-Hail
- Pharmacy Department, Women's Wellness and Research Center, Hamad Medical Corporation, Doha, Qatar.
| | - Mohammad Diab
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar.
| | - Scott Cunningham
- School of Pharmacy and Life Sciences, Robert Gordon University, UK.
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Sumon SA, Anwar MMU, Akther FM, Priyanka AS, Tamanna T, Rahman A, Islam MS, Harun MGD. Perceptions of antibiotic stewardship programmes and determinants of antibiotic prescribing patterns among physicians in tertiary hospitals in Bangladesh: implications for future policy and practice. J Hosp Infect 2024; 144:56-65. [PMID: 38070709 DOI: 10.1016/j.jhin.2023.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 11/16/2023] [Accepted: 11/20/2023] [Indexed: 01/11/2024]
Abstract
BACKGROUND The concerning growth of antimicrobial resistance (AMR) renders common infections life-threatening due to irrational antibiotic use and a lack of effective antimicrobial stewardship programmes (ASPs). AIM To investigate the awareness, perceptions and practices of physicians regarding ASPs, AMR and antibiotic prescribing in tertiary care hospitals in Bangladesh. METHODS This hospital-based cross-sectional survey was conducted in 11 tertiary care hospitals across Bangladesh between September 2020 and January 2021. A semi-structured questionnaire was administered through face-to-face interviews for data collection. Descriptive and multi-variate analyses were performed using STATA Version 13. RESULTS In total, 559 physicians were enrolled in this survey. Overall, 40.6% [95% confidence interval (CI) 36.5-44.8] of physicians reported being aware of ASPs, and this figure was higher in public hospitals compared with private hospitals (43.8% vs 27.1%). None of the study hospitals had any ASP initiatives. More than half (55.1%) of the participants were willing to receive feedback from an ASP on their antibiotic selection. Only 30.9% of respondents stated that they wait for the findings of microbiological tests before prescribing antibiotics, although challenges included empiric use of broad-spectrum antibiotics, delayed laboratory results and the existence of drug-resistant patients. In contrast, physicians aware of ASPs were 33% (adjusted odds ratio 0.67, 95% CI 0.45-0.98; P=0.033) less likely to wait for laboratory results before prescribing antibiotics. However, 42.5% of physicians considered patient affordability of purchasing antibiotics when prescribing. CONCLUSIONS Physicians' fundamental knowledge of ASPs and rational antibiotic prescription were found to fall short of the standard. Context-specific and integrated ASP activities, availability and use of guidelines, and improved laboratory facilities are required to battle AMR in Bangladesh.
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Affiliation(s)
- S A Sumon
- Infectious Diseases Division, icddr,b, Dhaka, Bangladesh.
| | - M M U Anwar
- Department of Population Sciences, University of Dhaka, Dhaka, Bangladesh
| | - F M Akther
- Infectious Diseases Division, icddr,b, Dhaka, Bangladesh
| | - A S Priyanka
- Infectious Diseases Division, icddr,b, Dhaka, Bangladesh
| | - T Tamanna
- Infectious Diseases Division, icddr,b, Dhaka, Bangladesh
| | - A Rahman
- Communicable Disease Control, Directorate General of Health Services, Dhaka, Bangladesh
| | - M S Islam
- School of Population Health, University of New South Wales, Sydney, Australia
| | - M G D Harun
- Infectious Diseases Division, icddr,b, Dhaka, Bangladesh
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Harun MGD, Sumon SA, Hasan I, Akther FM, Islam MS, Anwar MMU. Barriers, facilitators, perceptions and impact of interventions in implementing antimicrobial stewardship programs in hospitals of low-middle and middle countries: a scoping review. Antimicrob Resist Infect Control 2024; 13:8. [PMID: 38263235 PMCID: PMC10804809 DOI: 10.1186/s13756-024-01369-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 01/15/2024] [Indexed: 01/25/2024] Open
Abstract
BACKGROUND Antimicrobial stewardship programs (ASPs) are pivotal components of the World Health Organization's Global Action Plan to combat antimicrobial resistance (AMR). ASPs advocate rational antibiotic usage to enhance patient-centered outcomes. However, existing evidence on ASPs and their determinants is largely limited to well-equipped hospitals in high-income nations. OBJECTIVE This scoping review aimed to examine the current state of hospital-based ASPs in low- and middle-income countries (LMICs), shedding light on barriers, facilitators, prescribers' perceptions and practices, and the impact of ASP interventions. DESIGN Scoping review on ASP. METHODS Adhering to PRISMA guidelines, we conducted electronic database searches on PubMed, Scopus, and Google Scholar, covering ASP articles published between January 2015 and October 2023. Our review focused on four key domains: barriers to ASP implementation, facilitators for establishing ASP, ASP perceptions and practices of prescribers, and the impact of ASP interventions. Three reviewers separately retrieved relevant data from the included citations using EndNote 21.0. RESULTS Among the 7016 articles searched, 84 met the inclusion criteria, representing 34 LMICs. Notably, 58% (49/84) of these studies were published after 2020. Barriers to ASP implementation, including human-resources shortage, lack of microbiology laboratory support, absence of leadership, and limited governmental support, were reported by 26% (22/84) of the studies. Facilitators for hospital ASP implementation identified in five publications included the availability of antibiotic guidelines, ASP protocol, dedicated multidisciplinary ASP committee, and prompt laboratory support. The majority of the research (63%, 53/84) explored the impacts of ASP intervention on clinical, microbiological, and economic aspects. Key outcomes included increased antibiotic prescription appropriateness, reduced antimicrobial consumption, shorter hospital stays, decreased mortality rate, and reduced antibiotic therapy cost. CONCLUSIONS The published data underscores the imperative need for widespread antimicrobial stewardship in LMIC hospital settings. Substantial ASP success can be achieved through increasing human resources, context-specific interventions, the development of accessible antibiotic usage guidelines, and heightened awareness via training and education.
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Affiliation(s)
- Md Golam Dostogir Harun
- Infectious Diseases Division, icddr, b, 68 Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212, Bangladesh.
| | - Shariful Amin Sumon
- Infectious Diseases Division, icddr, b, 68 Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212, Bangladesh
| | - Istiaque Hasan
- Infectious Diseases Division, icddr, b, 68 Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212, Bangladesh
| | - Fairoze Masuda Akther
- Infectious Diseases Division, icddr, b, 68 Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212, Bangladesh
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Tjilos M, Drainoni ML, Burrowes SAB, Butler JM, Damschroder LJ, Bidwell Goetz M, Madaras-Kelly K, Reardon CM, Samore MH, Shen J, Stenehjem EA, Zhang Y, Barlam TF. A qualitative evaluation of frontline clinician perspectives toward antibiotic stewardship programs. Infect Control Hosp Epidemiol 2023; 44:1995-2001. [PMID: 36987859 PMCID: PMC10755145 DOI: 10.1017/ice.2023.35] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 02/02/2023] [Accepted: 02/04/2023] [Indexed: 03/30/2023]
Abstract
OBJECTIVE To examine the perspectives of caregivers that are not part of the antibiotic stewardship program (ASP) leadership team (eg, physicians, nurses, and clinical pharmacists), but who interact with ASPs in their role as frontline healthcare workers. DESIGN Qualitative semistructured interviews. SETTING The study was conducted in 2 large national healthcare systems including 7 hospitals in the Veterans' Health Administration and 4 hospitals in Intermountain Healthcare. PARTICIPANTS We interviewed 157 participants. The current analysis includes 123 nonsteward clinicians: 47 physicians, 26 pharmacists, 29 nurses, and 21 hospital leaders. METHODS Interviewers utilized a semistructured interview guide based on the Consolidated Framework for Implementation Research (CFIR), which was tailored to the participant's role in the hospital as it related to ASPs. Qualitative analysis was conducted using a codebook based on the CFIR. RESULTS We identified 4 primary perspectives regarding ASPs. (1) Non-ASP pharmacists considered antibiotic stewardship activities to be a high priority despite the added burden to work duties: (2) Nurses acknowledged limited understanding of ASP activities or involvement with these programs; (3) Physicians criticized ASPs for their restrictions on clinical autonomy and questioned the ability of antibiotic stewards to make recommendations without the full clinical picture; And (4) hospital leaders expressed support for ASPs and recognized the unique challenges faced by non-ASP clinical staff. CONCLUSION Further understanding these differing perspectives of ASP implementation will inform possible ways to improve ASP implementation across clinical roles.
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Affiliation(s)
- Maria Tjilos
- Department of Community Health Sciences, School of Public Health, Boston University, BostonMassachusetts
| | - Mari-Lynn Drainoni
- Section of Infectious Diseases, Department of Medicine, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
- Department of Health Law, Policy and Management, School of Public Health, Boston University, Boston, Massachusetts
- Evans Center for Implementation and Improvement Sciences, Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
| | - Shana A. B. Burrowes
- Section of Infectious Diseases, Department of Medicine, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
| | - Jorie M. Butler
- Division of Geriatrics, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
- Geriatric Education and Clinical Center and IDEAS Center of Innovation, Veterans’ Affairs (VA) Salt Lake City Health Care System, Salt Lake City, Utah
| | - Laura J. Damschroder
- VA Center for Clinical Management Research, Department of Veterans’ Affairs, Ann Arbor, Michigan
| | - Matthew Bidwell Goetz
- VA Greater Los Angeles Healthcare System, Los Angeles, California
- David Geffen School of Medicine, UCLA, Los Angeles, California
| | - Karl Madaras-Kelly
- Boise VA Medical Center, Boise, Idaho
- College of Pharmacy, Idaho State University, MeridianIdaho
| | - Caitlin M. Reardon
- VA Center for Clinical Management Research, Department of Veterans’ Affairs, Ann Arbor, Michigan
| | - Matthew H. Samore
- IDEAS Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, Utah
- Divison of Epidemiology, Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Jincheng Shen
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah
| | - Edward A. Stenehjem
- Division of Infectious Diseases and Epidemiology, Intermountain Healthcare, Salt Lake City, Utah
| | - Yue Zhang
- Divison of Epidemiology, Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Tamar F. Barlam
- Section of Infectious Diseases, Department of Medicine, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
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Bizri AR, El-Fattah AA, Bazaraa HM, Al Ramahi JW, Matar M, Ali RAN, El Masry R, Moussa J, Abbas AJA, Aziz MA. Antimicrobial resistance landscape and COVID-19 impact in Egypt, Iraq, Jordan, and Lebanon: A survey-based study and expert opinion. PLoS One 2023; 18:e0288550. [PMID: 37498951 PMCID: PMC10374138 DOI: 10.1371/journal.pone.0288550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 06/29/2023] [Indexed: 07/29/2023] Open
Abstract
OBJECTIVES The objective of this study was to assess the antimicrobial resistance (AMR) landscape and the impact of COVID-19 on AMR in Egypt, Iraq, Jordan, and Lebanon, and to gather expert opinions on the barriers to the implementation of antimicrobial stewardship (AMS) initiatives in the region. METHODS A cross-sectional questionnaire survey was used to assess the current AMR landscape, existing AMS initiatives, barriers to implementing AMS initiatives, and the impact of COVID-19 on AMR in the four countries. RESULTS The survey was completed by 204 physicians from Egypt (n = 82), Lebanon (n = 49), Iraq (n = 43), and Jordan (n = 30). Previous antibiotic use and previous bacterial colonization were perceived as the most common risk factors for an increase in AMR. According to the survey, multidrug-resistant (MDR) gram-negative bacteria were most common in lower respiratory tract infections, and Klebsiella pneumoniae and Escherichia coli were the most commonly identified gram-negative bacteria in hospital-acquired infections. Only 14.8% of pediatric physicians and 28.6% of adult physicians reported that target pathogen genotyping and phenotyping were done in hospitals, and the most commonly reported reasons for the lack of testing were technological and resource constraints. These constraints, coupled with the scarcity and high cost of newer antibiotics, have been identified as the most significant barriers to the successful management of MDR gram-negative bacterial infections in the region. It was reported that the spectrum of activity and safety of the antibiotic, the site of infection, the presence of comorbidities, and published guidelines and local antibiograms determined the choice of empirical antibiotic therapy for patients in the region. The four countries experienced a significant rise in AMR due to several factors during the COVID-19 pandemic, including an increase in hospital occupancy, a shift in priorities away from AMR surveillance, and changes in AMR epidemiology. Additionally, the large volumes of unnecessary and unsubstantiated antibiotic prescriptions during the COVID-19 pandemic has led to subsequent antibiotic shortages and significant increases in AMR in the region. Physicians also noted that the majority of COVID-19 patients were already on antibiotics before visiting the healthcare facility. MDR gram-negative bacteria were found in the majority of COVID-19 patients admitted to the intensive care unit. Despite the fact that various AMS initiatives have been implemented, they are not standardized across the region. Some of the main barriers to AMS implementation in the region are a lack of adequately trained AMS staff, lack of AMS knowledge and training among healthcare professionals, financial constraints, and the lack of AMR surveillance systems. CONCLUSION These survey results provide valuable insights into the existing AMR and AMS landscape in the region, as well as the barriers that impede efficient AMS and AMR management. Based on these findings, the authors developed a call to action that suggests ways for each country in the region to address these challenges.
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Affiliation(s)
- Abdul Rahman Bizri
- National COVID-19 Vaccine Committee, American University of Beirut Medical Center, Beirut, Lebanon
| | | | - Hafez Mahmoud Bazaraa
- Pediatric Critical Care Units, Department of Pediatrics, Faculty of Medicine, Cairo University, Giza, Egypt
| | | | - Madonna Matar
- Notre Dame des Secours University Hospital, Byblos, Lebanon
- Holy Spirit University of Kaslik, Byblos, Lebanon
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Zheng N, Li J, Liu Y, Liao K, Chen J, Zhang C, Wen W. Evaluation of Implementation and Effectiveness of China's Antibiotic Stewardship in the First Affiliated Hospital of Sun Yat-sen University. Antibiotics (Basel) 2023; 12:antibiotics12040770. [PMID: 37107132 PMCID: PMC10135032 DOI: 10.3390/antibiotics12040770] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 12/03/2022] [Accepted: 12/19/2022] [Indexed: 04/29/2023] Open
Abstract
Antibiotic stewardship has been prioritized by governments and health care organizations in recent years as antibiotic resistance is markedly increasing. A tertiary hospital in Guangzhou, China was chosen as a study example to undertake an implementation and effectiveness evaluation of China's antibiotic stewardship to improve and promote antimicrobial stewardship nationwide. The general surgery department of the study hospital was utilized to examine surgical site infection, and samples from across the hospital were used to identify bloodstream infection. Data was analyzed using descriptive analysis, the Mann-Kendall trend test, logit model and panel data model, and t-tests. In terms of prophylactic and therapeutic antibiotic rational use, respectively, we evaluated implementation conditions, the correlation between implementation and corresponding disease progress, and the cost-effectiveness of China's antibiotic stewardship. For perioperative prophylactic antibiotic use, antibiotic stewardship was found to have been well-implemented, cost-effective, and reduced the incidence of surgical site infection. However, concerning therapeutic use and antibiotic-resistant bacterial infection prophylaxis, the complexity of influencing factors and the contradiction between stewardship implementation and clinical demand needs to be further evaluated.
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Affiliation(s)
- Nianzhen Zheng
- Department of Otolaryngology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou Key Laboratory of Otorhinolaryngology, Otorhinolaryngology Institute of Sun Yat-sen University, Guangzhou 510080, China
| | - Jian Li
- Department of Otolaryngology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou Key Laboratory of Otorhinolaryngology, Otorhinolaryngology Institute of Sun Yat-sen University, Guangzhou 510080, China
| | - Yang Liu
- Information Data Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Kang Liao
- Room of Microbiology, Department of Medical Laboratory, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Jie Chen
- Department of Pharmacy, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Chengcheng Zhang
- Department of Otolaryngology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou Key Laboratory of Otorhinolaryngology, Otorhinolaryngology Institute of Sun Yat-sen University, Guangzhou 510080, China
| | - Weiping Wen
- Department of Otolaryngology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou Key Laboratory of Otorhinolaryngology, Otorhinolaryngology Institute of Sun Yat-sen University, Guangzhou 510080, China
- Department of Otolaryngology, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou 510655, China
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12
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Wojcik G, Ring N, Willis DS, Williams B, Kydonaki K. Improving antibiotic use in hospitals: development of a digital antibiotic review tracking toolkit (DARTT) using the behaviour change wheel. Psychol Health 2023:1-21. [PMID: 36855847 DOI: 10.1080/08870446.2023.2182894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 12/07/2022] [Accepted: 02/15/2023] [Indexed: 03/02/2023]
Abstract
OBJECTIVE To develop a theory-informed behaviour change intervention to promote appropriate hospital antibiotic use, guided by the Medical Research Council's complex interventions framework. METHODS A phased approach was used, including triangulation of data from meta-ethnography and two qualitative studies. Central to intervention design was the generation of a robust theoretical basis using the Behaviour Change Wheel to identify relevant determinants of behaviour change and intervention components. Intervention content was guided by APEASE (Acceptability, Practicability, Effectiveness, Affordability, Side-effects, and Equity) criteria and coded using a Behaviour Change Technique Taxonomy. Stakeholders were involved throughout. RESULTS From numerous modifiable prescribing behaviours identified, active 'antibiotic time-out' was selected as the target behaviour to help clinicians safely initiate antibiotic reassessment. Prescribers' capability, opportunity, and motivation were potential drivers for changing this behaviour. The design process resulted in the selection of 25 behaviour change techniques subsequently translated into intervention content. Integral to this work was the development and refinement of a Digital Antibiotic Review Tracking Toolkit. CONCLUSION This novel work demonstrates how the Behaviour Change Wheel can be used with the Medical Research Council framework to develop a theory-based behaviour change intervention targeting barriers to timely hospital antibiotic reassessment. Future research will evaluate the Antibiotic Toolkit's feasibility and effectiveness.
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Affiliation(s)
- Gosha Wojcik
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - N Ring
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - D S Willis
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - B Williams
- School of Health, Social Care & Life Sciences, University of Highlands and Islands, Inverness, UK
| | - K Kydonaki
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
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Stemkens R, Schouten JA, van Kessel SAM, Akkermans RP, Telgt DSC, Fleuren HWHA, Claassen MAA, Hulscher MEJL, Ten Oever J. How to use quality indicators for antimicrobial stewardship in your hospital: a practical example on outpatient parenteral antimicrobial therapy. Clin Microbiol Infect 2023; 29:182-187. [PMID: 35843564 DOI: 10.1016/j.cmi.2022.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 07/08/2022] [Accepted: 07/11/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Antimicrobial stewardship (AMS) teams are responsible for performing an AMS programme in their hospitals that aims to improve the quality of antibiotic use. Measuring the quality of antimicrobial use is a core task of a stewardship team. Measurement provides insight into the current quality of antibiotic use and allows for the establishment of goals for improvement. Yet, a practical description of how such a quality measurement using quality indicators (QIs) should be performed is lacking. OBJECTIVES To provide practical guidance on how a stewardship team can use QIs to measure the quality of antibiotic use in their hospital and identify targets for improvement. SOURCES General principles from implementation science, peer-reviewed publications, and experience from clinicians and researchers with AMS experience. CONTENT We provide step-by-step guidance on how AMS teams can use QIs to measure the quality of antibiotic use. The principles behind each step are explained and illustrated with the description and results of an audit of patients receiving outpatient parenteral antimicrobial therapy in four Dutch hospitals. IMPLICATIONS Improving the quality of antibiotic use is impossible without first gaining insight into that quality by performing a measurement with validated QIs. This step-by-step practice example of how to use quality indicators in a hospital will help AMS teams to identify targets for improvement. This enables them to perform their AMS programme more effectively and efficiently.
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Affiliation(s)
- Ralf Stemkens
- Department of Pharmacy and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jeroen A Schouten
- Department of Intensive Care Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Sophie A M van Kessel
- Department of Intensive Care Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Reinier P Akkermans
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Institute for Quality of Healthcare, Nijmegen, The Netherlands; Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Primary and Community Care, Nijmegen, The Netherlands
| | - Denise S C Telgt
- Department of Internal Medicine, Sint Maartenskliniek, Ubbergen, The Netherlands; Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | | | - Marlies E J L Hulscher
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Institute for Quality of Healthcare, Nijmegen, The Netherlands
| | - Jaap Ten Oever
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands.
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Li G, Walker MJ, De Oliveira DMP. Vancomycin Resistance in Enterococcus and Staphylococcus aureus. Microorganisms 2022; 11:microorganisms11010024. [PMID: 36677316 PMCID: PMC9866002 DOI: 10.3390/microorganisms11010024] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 12/19/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
Enterococcus faecalis, Enterococcus faecium and Staphylococcus aureus are both common commensals and major opportunistic human pathogens. In recent decades, these bacteria have acquired broad resistance to several major classes of antibiotics, including commonly employed glycopeptides. Exemplified by resistance to vancomycin, glycopeptide resistance is mediated through intrinsic gene mutations, and/or transferrable van resistance gene cassette-carrying mobile genetic elements. Here, this review will discuss the epidemiology of vancomycin-resistant Enterococcus and S. aureus in healthcare, community, and agricultural settings, explore vancomycin resistance in the context of van and non-van mediated resistance development and provide insights into alternative therapeutic approaches aimed at treating drug-resistant Enterococcus and S. aureus infections.
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Puro V, Coppola N, Frasca A, Gentile I, Luzzaro F, Peghetti A, Sganga G. Pillars for prevention and control of healthcare-associated infections: an Italian expert opinion statement. Antimicrob Resist Infect Control 2022; 11:87. [PMID: 35725502 PMCID: PMC9207866 DOI: 10.1186/s13756-022-01125-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 06/07/2022] [Indexed: 01/04/2023] Open
Abstract
Healthcare-associated infections (HAIs) represent a relevant problem for all healthcare facilities, because they involve both the care aspect and the economic management of the hospital. Most HAIs are preventable through effective Infection Prevention and Control (IPC) measures. Implementation and improvement of IPC programs are critical to reducing the impact of these infections and the spread of multi-resistant microorganisms. The purpose of this Expert Opinion statement was to provide a practical guide for healthcare organizations, physicians, and nursing staff on the optimal implementation of the core components of Infection Prevention and Control, as recommended by a board of specialists after in-depth discussion of the available evidence in this field. According to their independent suggestions and clinical experiences, as well as evidence-based practices and literature review, this document provides a practical bundle of organizational, structural, and professional requirements necessary to promote, through multimodal strategies, the improvement of the quality and safety of care with respect to infectious risk in order to protect the patient, facilities, and healthcare providers.
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Alkhawaldeh R, Abu Farha R, Abu Hammour K, Alefishat E. Optimizing antimicrobial therapy in urinary tract infections: A focus on urine culture and sensitivity testing. Front Pharmacol 2022; 13:1058669. [PMID: 36532780 PMCID: PMC9748416 DOI: 10.3389/fphar.2022.1058669] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 11/15/2022] [Indexed: 09/29/2023] Open
Abstract
Objectives: This cross-sectional study was conducted at Jordan university hospital to evaluate the impact of microbial culture data and sensitivity results on optimizing UTI treatment. Methods: All positive urine cultures requested for adult patients (≥18 years) admitted to Jordan University Hospital (JUH) within the period from January 2019-July 2021 were evaluated. The antibiotics prescribed before and after culture data and sensitivity results were compared to evaluate the impact of these diagnostic measures on optimizing UTI treatment. Results: During the study period, 2400 urine cultures revealed positive results. Among those patients, 1,600 (66.7%) were discharged before the availability of culture results and excluded. Of the remaining 800 patients, 701 patients (87.6%) received empiric treatment. After culture and sensitivity results were available, overall, 84 (10.5%) patients had optimization (improvement) in their UTI management after culture results were known, while 6 (0.8%) patients had a worsening in their treatments. Based on the culture results, we found that only 12.4% of patients were appropriately treated before and after the culture results. Moreover, our results revealed that 31.9% were inappropriately treated for their UTIs before and after culture results. Conclusion: This study revealed an alarmingly high rate of inappropriate treatment of UTIs despite the availability of urine culture and sensitivity data, and that culture results were not used to optimize treatment strategies for UTI. This practice can potentially result in poor health-related outcomes and adversely affects efforts to battle AMR. Multifaceted strategies must be implemented to help clinicians follow the best current evidence and current guidelines in their selection of antibiotics for the management of UTIs.
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Affiliation(s)
- Rama Alkhawaldeh
- Department of Clinical Pharmacy, Faculty of Pharmacy, Applied Science Private University, Amman, Jordan
| | - Rana Abu Farha
- Department of Clinical Pharmacy, Faculty of Pharmacy, Applied Science Private University, Amman, Jordan
| | - Khawla Abu Hammour
- Department Biopharmaceutics and Clinical Pharmacy, Faculty of Pharmacy, The University of Jordan, Amman, Jordan
| | - Eman Alefishat
- Department Biopharmaceutics and Clinical Pharmacy, Faculty of Pharmacy, The University of Jordan, Amman, Jordan
- Department of Pharmacology, College of Medicine and Health Science, Khalifa University of Science and Technology, Abu Dhabi, United Arab Emirates
- Center for Biotechnology, Khalifa University of Science and Technology, Abu Dhabi, United Arab Emirates
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Durant DJ, Guerrazzi-Young C. EVALUATION OF A STATEWIDE COLLABORATIVE FOCUSED ON ANTIBIOITC USAGE SURVEILLANCE AND STEWARDSHIP IN NEW YORK STATE HOSPITALS. Am J Infect Control 2022:S0196-6553(22)00809-4. [DOI: 10.1016/j.ajic.2022.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 11/11/2022] [Accepted: 11/12/2022] [Indexed: 11/19/2022]
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Waagsbø B, Tranung M, Damås JK, Heggelund L. Antimicrobial therapy of community-acquired pneumonia during stewardship efforts and a coronavirus pandemic: an observational study. BMC Pulm Med 2022; 22:379. [PMID: 36242006 PMCID: PMC9569007 DOI: 10.1186/s12890-022-02178-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 09/09/2022] [Accepted: 09/26/2022] [Indexed: 11/23/2022] Open
Abstract
Background Community-acquired pneumonia (CAP) is the most frequent infection diagnosis in hospitals. Antimicrobial therapy for CAP is depicted in clinical practice guidelines, but adherence data and effect of antibiotic stewardship measures are lacking. Methods A dedicated antibiotic team pointed out CAP as a potential target for antimicrobial stewardship (AMS) measures at a 1.000-bed, tertiary care, teaching university hospital in Norway from March until May for the years 2016 throughout 2021. The aim of the AMS program was to increase diagnostic and antimicrobial therapy adherence to national clinical practice guideline recommendations through multiple and continuous AMS efforts. Descriptive statistics were retrospectively used to delineate antimicrobial therapy for CAP. The primary outcomes were proportions that received narrow-spectrum beta-lactams, and broad-spectrum antimicrobial therapy. Results 1.112 CAP episodes were identified. The annual proportion that received narrow-spectrum beta-lactams increased from 56.1 to 74.4% (p = 0.045). Correspondingly, the annual proportion that received broad-spectrum antimicrobial therapy decreased from 34.1 to 17.1% (p = 0.002). Trends were affected by the coronavirus pandemic. Mortality and 30-day readmission rates remained unchanged. De-escalation strategies were frequently unutilized, and overall therapy duration exceeded clinical practice guideline recommendations substantially. Microbiologically confirmed CAP episodes increased from 33.7 to 56.2% during the study period. Conclusion CAP is a suitable model condition that is sensitive to AMS measures. A continuous focus on improved microbiological diagnostics and antimicrobial therapy initiation is efficient in increasing adherence to guideline recommendations. There is an unmet need for better antimicrobial de-escalation strategies. Supplementary Information The online version contains supplementary material available at 10.1186/s12890-022-02178-6.
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Affiliation(s)
- Bjørn Waagsbø
- St. Olavs Hospital, Regional centre for disease control in Central Norway Regional Health Authority, Trondheim University hospital, Trondheim, Norway. .,Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway.
| | - Morten Tranung
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway.,Central Norway Hospital Pharmacy Trust, Trondheim, Norway
| | - Jan Kristian Damås
- Department of Infectious Diseases, St. Olavs Hospital, Trondheim University hospital, Trondheim, Norway.,Centre of Molecular Inflammation Research, department of Clinical and Molecular Medicine, NTNU, Trondheim, Norway
| | - Lars Heggelund
- Department of Internal Medicine, Drammen Hospital, Vestre Viken Hospital Trust, Drammen, Norway.,Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway
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Catho G, Sauser J, Coray V, Da Silva S, Elzi L, Harbarth S, Kaiser L, Marti C, Meyer R, Pagnamenta F, Portela J, Prendki V, Ranzani A, Centemero NS, Stirnemann J, Valotti R, Vernaz N, Suter BW, Bernasconi E, Huttner BD. Impact of interactive computerised decision support for hospital antibiotic use (COMPASS): an open-label, cluster-randomised trial in three Swiss hospitals. THE LANCET INFECTIOUS DISEASES 2022; 22:1493-1502. [PMID: 35870478 PMCID: PMC9491854 DOI: 10.1016/s1473-3099(22)00308-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 05/03/2022] [Accepted: 05/04/2022] [Indexed: 11/12/2022]
Abstract
Background Computerised decision-support systems (CDSSs) for antibiotic stewardship could help to assist physicians in the appropriate prescribing of antibiotics. However, high-quality evidence for their effect on the quantity and quality of antibiotic use remains scarce. The aim of our study was to assess whether a computerised decision support for antimicrobial stewardship combined with feedback on prescribing indicators can reduce antimicrobial prescriptions for adults admitted to hospital. Methods The Computerised Antibiotic Stewardship Study (COMPASS) was a multicentre, cluster-randomised, parallel-group, open-label superiority trial that aimed to assess whether a multimodal computerised antibiotic-stewardship intervention is effective in reducing antibiotic use for adults admitted to hospital. After pairwise matching, 24 wards in three Swiss tertiary-care and secondary-care hospitals were randomised (1:1) to the CDSS intervention or to standard antibiotic stewardship measures using an online random sequence generator. The multimodal intervention consisted of a CDSS providing support for choice, duration, and re-evaluation of antimicrobial therapy, and feedback on antimicrobial prescribing quality. The primary outcome was overall systemic antibiotic use measured in days of therapy per admission, using adjusted-hurdle negative-binomial mixed-effects models. The analysis was done by intention to treat and per protocol. The study was registered with ClinicalTrials.gov (identifier NCT03120975). Findings 24 clusters (16 at Geneva University Hospitals and eight at Ticino Regional Hospitals) were eligible and randomly assigned to control or intervention between Oct 1, 2018, and Dec 31, 2019. Overall, 4578 (40·2%) of 11 384 admissions received antibiotic therapy in the intervention group and 4142 (42·8%) of 9673 in the control group. The unadjusted overall mean days of therapy per admission was slightly lower in the intervention group than in the control group (3·2 days of therapy per admission, SD 6·2, vs 3·5 days of therapy per admission, SD 6·8; p<0·0001), and was similar among patients receiving antibiotics (7·9 days of therapy per admission, SD 7·6, vs 8·1 days of therapy per admission, SD 8·4; p=0·50). After adjusting for confounders, there was no statistically significant difference between groups for the odds of an admission receiving antibiotics (odds ratio [OR] for intervention vs control 1·12, 95% CI 0·94–1·33). For admissions with antibiotic exposure, days of therapy per admission were also similar (incidence rate ratio 0·98, 95% CI 0·90–1·07). Overall, the CDSS was used at least once in 3466 (75·7%) of 4578 admissions with any antibiotic prescription, but from the first day of antibiotic treatment for only 1602 (58·9%) of 2721 admissions in Geneva. For those for whom the CDSS was not used from the first day, mean time to use of CDSS was 8·9 days. Based on the manual review of 1195 randomly selected charts, transition from intravenous to oral therapy was significantly more frequent in the intervention group after adjusting for confounders (154 [76·6%] of 201 vs 187 [87%] of 215, +10·4%; OR 1·9, 95% CI 1·1–3·3). Consultations by infectious disease specialists were less frequent in the intervention group (388 [13·4%] of 2889) versus the control group (405 [16·9%] of 2390; OR 0·84, 95% CI 0·59–1·25). Interpretation An integrated multimodal computerised antibiotic stewardship intervention did not significantly reduce overall antibiotic use, the primary outcome of the study. Contributing factors were probably insufficient uptake, a setting with relatively low antibiotic use at baseline, and delays between ward admission and first CDSS use. Funding Swiss National Science Foundation. Translations For the French and Italian translations of the abstract see Supplementary Materials section.
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Stoorvogel HH, Hulscher MEJL, Wertheim HFL, Yzerman EPF, Scholing M, Schouten JA, ten Oever J. Current Practices and Opportunities for Outpatient Parenteral Antimicrobial Therapy in Hospitals: A National Cross-Sectional Survey. Antibiotics (Basel) 2022; 11:antibiotics11101343. [PMID: 36290001 PMCID: PMC9598700 DOI: 10.3390/antibiotics11101343] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 09/28/2022] [Accepted: 09/28/2022] [Indexed: 11/07/2022] Open
Abstract
This nationwide study assessed how outpatient parenteral antimicrobial therapy (OPAT) is organised by Dutch acute care hospitals, the barriers experienced, and how an OPAT program affects the way hospitals organised OPAT care. We systematically developed and administered a survey to all 71 Dutch acute care hospitals between November 2021 and February 2022. Analyses were primarily descriptive and included a comparison between hospitals with and without an OPAT program. Sixty of the 71 hospitals (84.5%) responded. Fifty-five (91.7%) performed OPAT, with a median number of 20.8 (interquartile range [IQR] 10.3-29.7) patients per 100 hospital beds per year. Of these 55 hospitals, 31 (56.4%) had selection criteria for OPAT and 34 (61.8%) had a protocol for laboratory follow-up. Sixteen hospitals (29.1%) offered self-administered OPAT (S-OPAT), with a median percentage of 5.0% of patients (IQR: 2.3%-10.0%) actually performing self-administration. Twenty-five hospitals (45.5%) had an OPAT-related outcome registration. The presence of an OPAT program (22 hospitals, 40.0%) was significantly associated with aspects of well-organised OPAT care. The most commonly experienced barriers to OPAT implementation were a lack of financial, administrative, and IT support and insufficient time of healthcare staff. Concluding, hospital-initiated OPAT is widely available in the Netherlands, but various aspects of well-organised OPAT care can be improved. Implementation of a team-based OPAT program can contribute to such improvements. The observed variation provides leads for further scientific research, guidelines, and practical implementation programs.
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Affiliation(s)
- Hester H. Stoorvogel
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Internal Medicine & IQ Healthcare, Radboud Center for Infectious Diseases, 6500HB Nijmegen, The Netherlands
- Correspondence:
| | - Marlies E. J. L. Hulscher
- Radboud University Medical Center, Department of IQ Healthcare, Radboud Center for Infectious Diseases, 6500HB Nijmegen, The Netherlands
| | - Heiman F. L. Wertheim
- Radboud University Medical Center, Department of Medical Microbiology, Radboud Center for Infectious Diseases, 6500HB Nijmegen, The Netherlands
| | - Ed P. F. Yzerman
- ABR Zorgnetwerk Noord-Holland–Flevoland, 1105AZ Amsterdam, The Netherlands
| | - Maarten Scholing
- ABR Zorgnetwerk Noord-Holland–Flevoland, 1105AZ Amsterdam, The Netherlands
- OLVG Lab BV, 1091AC Amsterdam, The Netherlands
| | - Jeroen A. Schouten
- Radboud University Medical Center, Department of Intensive Care & IQ Healthcare, Radboud Center for Infectious Diseases, 6500HB Nijmegen, The Netherlands
| | - Jaap ten Oever
- Radboud University Medical Center, Department of Internal Medicine, Radboud Center for Infectious Diseases, 6500HB Nijmegen, The Netherlands
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Limato R, Lazarus G, Dernison P, Mudia M, Alamanda M, Nelwan EJ, Sinto R, Karuniawati A, Rogier van Doorn H, Hamers RL. Optimizing antibiotic use in Indonesia: A systematic review and evidence synthesis to inform opportunities for intervention. THE LANCET REGIONAL HEALTH. SOUTHEAST ASIA 2022; 2:100013. [PMID: 37383293 PMCID: PMC10305907 DOI: 10.1016/j.lansea.2022.05.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
Background A major driver of antimicrobial resistance (AMR) and poor clinical outcomes is suboptimal antibiotic use, although data are lacking in low-resource settings. We reviewed studies on systemic antibiotic use (WHO ATC/DDD category J01) for human health in Indonesia, and synthesized available evidence to identify opportunities for intervention. Methods We systematically searched five international and national databases for eligible peer-reviewed articles, in English and Indonesian, published between 1 January 2000 and 1 June 2021 including: (1) antibiotic consumption; (2) prescribing appropriateness; (3) antimicrobial stewardship (AMS); (4) consumers' and providers' perceptions. Two independent reviewers included studies and extracted data. Study-level data were summarized using random-effects model meta-analysis for consumption and prescribing appropriateness, effect direction analysis for antimicrobial stewardship (AMS) interventions, and qualitative synthesis for perception surveys. (PROSPERO: CRD42019134641). Findings Of 9323 search hits, we included 100 reports on antibiotic consumption (20), prescribing appropriateness (49), AMS interventions (13), and/or perception (25) (8 categorized in >1 domain). The pooled estimate of overall antibiotic consumption was 134.8 DDD per 100 bed-days (95%CI 82.5-187.0) for inpatients and 121.1 DDD per 1000 inhabitants per day (10.4-231.8) for outpatients. Ceftriaxone, levofloxacin, and ampicillin were the most consumed antibiotics in inpatients, and amoxicillin, ciprofloxacin, and cefadroxil in outpatients. Pooled estimates for overall appropriate prescribing (according to Gyssens method) were 33.5% (18.1-53.4) in hospitals and 49.4% (23.7-75.4) in primary care. Pooled estimates for appropriate prescribing (according to reference guidelines) were, in hospitals, 99.7% (97.4-100) for indication, 84.9% (38.5-98.0) for drug choice, and 6.1% (0.2-63.2) for overall appropriateness, and, in primary care, 98.9% (60.9-100) for indication, 82.6% (50.5-95.7) for drug choice and 10.5% (0.8-62.6) for overall appropriateness. Studies to date evaluating bundled AMS interventions, although sparse and heterogeneous, suggested favourable effects on antibiotic consumption, prescribing appropriateness, guideline compliance, and patient outcomes. Key themes identified in perception surveys were lack of community antibiotic knowledge, and common non-prescription antibiotic self-medication. Interpretation Context-specific intervention strategies are urgently needed to improve appropriate antibiotic use in Indonesian hospitals and communities, with critical evidence gaps concerning the private and informal healthcare sectors. Funding Wellcome Africa Asia Programme Vietnam.
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Affiliation(s)
- Ralalicia Limato
- Eijkman-Oxford Clinical Research Unit, Jakarta, Indonesia
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Gilbert Lazarus
- Eijkman-Oxford Clinical Research Unit, Jakarta, Indonesia
- Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Puck Dernison
- Eijkman-Oxford Clinical Research Unit, Jakarta, Indonesia
- Faculty of Health Sciences, Radboud University Medical Centre, Nijmegen, the Netherlands
| | | | - Monik Alamanda
- Eijkman-Oxford Clinical Research Unit, Jakarta, Indonesia
| | - Erni J. Nelwan
- Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
- Department of Internal Medicine, Division of Infectious Diseases, Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia
| | - Robert Sinto
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
- Department of Internal Medicine, Division of Infectious Diseases, Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia
| | - Anis Karuniawati
- Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
- Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia
| | - H. Rogier van Doorn
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford University Clinical Research Unit, Hanoi, Vietnam
| | - Raph L. Hamers
- Eijkman-Oxford Clinical Research Unit, Jakarta, Indonesia
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
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Omosa-Manyonyi GS, Koyio LN, Mwangi EW, Gathura H, van der Ven A, Oever JT. Inadequacies in service delivery for the diagnosis and treatment of vaginitis and vaginosis in Nairobi, Kenya. Int J STD AIDS 2022; 33:584-596. [PMID: 35380482 DOI: 10.1177/09564624221087533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Vulvovaginal candidiasis (VVC), a common cause of vaginitis, affects 75% of women in their lifetime. In Kenya, vaginitis/VVC is managed using the vaginal discharge syndrome guidelines. We assessed how frequently healthcare workers consider the diagnosis of vaginitis/VVC in symptomatic women, and adherence to the syndromic guidelines, outpatient records at Nairobi City County health facilities, of non-pregnant symptomatic females aged ≥15 years were abstracted. Descriptive statistics were applied, and analysis of determinants of practice determined using multivariable logistic regression models. Of 6,516 patients, 4,236 (65%) (inter-facility range 11-92%) had vaginitis of which 1,554 (37%) were considered VVC (inter-facility range 0-99%). Vaginitis was associated with facility, adjusted odds ratio (aOR) 2.80 (95% confidence interval (CI) 1.64-4.76) and aOR 0.03 (95% CI 0.02-0.04); and month, aOR 0.33 (95% CI 0.25-0.43). Vaginal examination was in 53% (inter-facility range 0-98%). Adherence to syndromic treatment was 56% (inter-facility range 0-83%), better with older patients (aOR 7.73, 95% CI 3.31-18.07). Vaginitis and VVC are commonly diagnosed in symptomatic patients in Nairobi; adherence to the syndromic guidelines is low and differs across the health facilities. Interventions to improve adherence are needed.
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Affiliation(s)
| | | | | | | | | | - Jaap Ten Oever
- 569645Radboud University Medical Center, Nijmegen, Netherlands
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van Heijl I, Schweitzer VA, van der Linden PD, van Werkhoven CH, Bonten MJM. Antibiotic stewardship in the real world - Authors' reply. THE LANCET. INFECTIOUS DISEASES 2022; 22:449. [PMID: 35338867 DOI: 10.1016/s1473-3099(22)00145-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 02/18/2022] [Indexed: 06/14/2023]
Affiliation(s)
- Inger van Heijl
- Julius Centre for Health Sciences and Primary Care, Utrecht, Netherlands; Department of Clinical Pharmacy, Tergooi Hospital, Hilversum, Netherlands
| | - Valentijn A Schweitzer
- Department of Medical Microbiology, University Medical Centre Utrecht, Utrecht, Netherlands.
| | | | | | - Marc J M Bonten
- Julius Centre for Health Sciences and Primary Care, Utrecht, Netherlands; Department of Medical Microbiology, University Medical Centre Utrecht, Utrecht, Netherlands
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Christensen I, Haug JB, Berild D, Bjørnholt JV, Skodvin B, Jelsness-Jørgensen LP. Factors Affecting Antibiotic Prescription among Hospital Physicians in a Low-Antimicrobial-Resistance Country: A Qualitative Study. Antibiotics (Basel) 2022; 11:antibiotics11010098. [PMID: 35052975 PMCID: PMC8773165 DOI: 10.3390/antibiotics11010098] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 01/05/2022] [Accepted: 01/11/2022] [Indexed: 02/05/2023] Open
Abstract
Antimicrobial resistance (AMR) is a threat to hospital patients. Antimicrobial stewardship programs (ASPs) can counteract AMR. To optimize ASPs, we need to understand what affects physicians’ antibiotic prescription from several contexts. In this study, we aimed to explore the factors affecting hospital physicians’ antibiotic choices in a low-resistance country to identify potential targets for future ASPs. We interviewed 14 physicians involved in antibiotic prescription in a Norwegian hospital. The interviews were audiotaped, transcribed verbatim, and analyzed using thematic analysis. The main factors affecting antibiotic prescription were a high work pressure, insufficient staff resources, and uncertainties regarding clinical decisions. Treatment expectations from patients and next of kin, benevolence towards the patients, suboptimal microbiological testing, and limited time for infectious disease specialists to offer advisory services also affected the antibiotic choices. Future ASP efforts should evaluate the system organization and prioritizations to address and manage potential time-pressure issues. To limit the use of broad-spectrum antibiotics, improving microbiology testing and the routines for consultations with infectious disease specialists seems beneficial. We also identified a need among the prescribing physicians for a debate on ethical antibiotic questions.
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Affiliation(s)
- Ingrid Christensen
- Department of Infection Control, Østfold Hospital Trust, Kalnes, 1714 Graalum, Norway; (J.B.H.); (L.-P.J.-J.)
- Faculty of Medicine, Ph.D. Program Medicine and Health Sciences, University of Oslo, 0315 Oslo, Norway
- Correspondence: ; Tel.: +47-9073-3113; Fax: +47-6986-4885
| | - Jon Birger Haug
- Department of Infection Control, Østfold Hospital Trust, Kalnes, 1714 Graalum, Norway; (J.B.H.); (L.-P.J.-J.)
| | - Dag Berild
- Department of Infectious Diseases, Oslo University Hospital, 0424 Oslo, Norway;
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, 0315 Oslo, Norway;
| | - Jørgen Vildershøj Bjørnholt
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, 0315 Oslo, Norway;
- Department of Microbiology, Oslo University Hospital, 0424 Oslo, Norway
| | - Brita Skodvin
- Norwegian Advisory Unit on Antibiotic Use in Hospitals, Department of Research and Development, Haukeland University Hospital, 5021 Bergen, Norway;
| | - Lars-Petter Jelsness-Jørgensen
- Department of Infection Control, Østfold Hospital Trust, Kalnes, 1714 Graalum, Norway; (J.B.H.); (L.-P.J.-J.)
- Faculty of Health and Social Studies, Østfold University College, 1671 Fredrikstad, Norway
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25
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Janssen RME, Oerlemans AJM, Van Der Hoeven JG, Ten Oever J, Schouten JA, Hulscher MEJL. OUP accepted manuscript. J Antimicrob Chemother 2022; 77:2105-2119. [PMID: 35612930 PMCID: PMC9333408 DOI: 10.1093/jac/dkac162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 05/02/2022] [Indexed: 11/14/2022] Open
Abstract
Background In daily hospital practice, antibiotic therapy is commonly prescribed for longer than recommended in guidelines. Understanding the key drivers of prescribing behaviour is crucial to generate meaningful interventions to bridge this evidence-to-practice gap. Objectives To identify behavioural determinants that might prevent or enable improvements in duration of antibiotic therapy in daily practice. Methods We systematically searched PubMed, Embase, PsycINFO and Web of Science for relevant studies that were published between January 2000 and August 2021. All qualitative, quantitative and mixed-method studies in adults in a hospital setting that reported determinants of antibiotic therapy duration were included. Results Twenty-two papers were included in this review. A first set of studies provided 82 behavioural determinants that shape how health professionals make decisions about duration; most of these were related to individual health professionals’ knowledge, skills and cognitions, and to professionals’ interactions. A second set of studies provided 17 determinants that point to differences in duration regarding various pathogens, diseases, or patient, professional or hospital department characteristics, but do not explain why or how these differences occur. Conclusions Limited literature is available describing a wide range of determinants that influence duration of antibiotic therapy in daily practice. This review provides a stepping stone for the development of stewardship interventions to optimize antibiotic therapy duration, but more research is warranted. Stewardship teams must develop complex improvement interventions to address the wide variety of behavioural determinants, adapted to the specific pathogen, disease, patient, professional and/or hospital department involved.
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Affiliation(s)
| | - Anke J M Oerlemans
- Scientific Center for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Johannes G Van Der Hoeven
- Department of Intensive Care Medicine, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jaap Ten Oever
- Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Internal Medicine, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jeroen A Schouten
- Department of Intensive Care Medicine, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- Scientific Center for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marlies E J L Hulscher
- Scientific Center for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands
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Narrow-spectrum antibiotics for community-acquired pneumonia in Dutch adults (CAP-PACT): a cross-sectional, stepped-wedge, cluster-randomised, non-inferiority, antimicrobial stewardship intervention trial. THE LANCET. INFECTIOUS DISEASES 2021; 22:274-283. [PMID: 34627499 DOI: 10.1016/s1473-3099(21)00255-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 03/11/2021] [Accepted: 04/12/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Adults hospitalised to a non-intensive care unit (ICU) ward with moderately severe community-acquired pneumonia are frequently treated with broad-spectrum antibiotics, despite Dutch guidelines recommending narrow-spectrum antibiotics. Therefore, we investigated whether an antibiotic stewardship intervention would reduce the use of broad-spectrum antibiotics in patients with moderately severe community-acquired pneumonia without compromising their safety. METHODS In this cross-sectional, stepped-wedge, cluster-randomised, non-inferiority trial (CAP-PACT) done in 12 hospitals in the Netherlands, we enrolled immunocompetent adults (≥18 years) who were admitted to a non-ICU ward and had a working diagnosis of moderately severe community-acquired pneumonia. All participating hospitals started in a control period and every 3 months a block of two hospitals transitioned from the control to the intervention period, with all hospitals eventually ending in the intervention period. The unit of randomisation was the hospital (cluster), and electronic randomisation (by an independent data manager) decided the sequence (the time of intervention) by which hospitals would cross over from the control period to the intervention period. Blinding was not possible. The antimicrobial stewardship intervention was a bundle targeting health-care providers and comprised education, engaging opinion leaders, and prospective audit and feedback of antibiotic use. The co-primary outcomes were broad-spectrum days of therapy per patient, tested by superiority, and 90-day all-cause mortality, tested by non-inferiority with a non-inferiority margin of 3%, and were analysed in the intention-to-treat population, comprising all patients who were enrolled in the control and intervention periods. This trial was prospectively registered at ClinicalTrials.gov, NCT02604628. FINDINGS Between Nov 1, 2015, and Nov 1, 2017, 5683 patients were assessed for eligibility, of whom 4084 (2235 in the control period and 1849 in the intervention period) were included in the intention-to-treat analysis. The adjusted mean broad-spectrum days of therapy per patient were reduced from 6·5 days in the control period to 4·8 days in the intervention period, yielding an absolute reduction of -1·7 days (95% CI -2·4 to -1·1) and a relative reduction of 26·6% (95% CI 18·0-35·3). Crude 90-day mortality was 10·9% (242 of 2228 died) in the control period and 10·8% (199 of 1841) in the intervention period, yielding an adjusted absolute risk difference of 0·4% (90% CI -2·7 to 2·4), indicating non-inferiority. INTERPRETATION In patients hospitalised with moderately severe community-acquired pneumonia, a multifaceted antibiotic stewardship intervention might safely reduce broad-spectrum antibiotic use. FUNDING None.
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Mzumara GW, Mambiya M, Iroh Tam PY. Antimicrobial stewardship interventions in least developed and low-income countries: a systematic review protocol. BMJ Open 2021; 11:e047312. [PMID: 34385248 PMCID: PMC8362704 DOI: 10.1136/bmjopen-2020-047312] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Antimicrobial resistance (AMR) is increasing in low resource settings. It complicates the management of infectious diseases and is an increasing cause of death. This is due to, among other things, lack of health resources for appropriate diagnosis and unregulated access to antimicrobials in the public sphere. Developing context-specific interventions that enable judicious use of antimicrobials is important to curb this problem. METHODS We will conduct a systematic review of antimicrobial stewardship (AMS) approaches in Development Assistance Committee in least developed and low-income countries. The inclusion criteria are antimicrobial stewardship interventions in hospitalised patients of all age groups and exclusion criteria are community-based trials and studies that solely focus on viral, fungal or parasite infections. Antimicrobial stewardship interventions will be classified as structural, enabling, persuasive, restrictive or combined. Outcomes of included studies will be classified as clinical, microbiological or behavioural outcomes. The studies to be included will be randomised controlled trials, controlled before-after studies, interrupted time series trials, cohort and qualitative studies. Data will be extracted using forms adapted from the Cochrane collaboration data collection form. This systematic review will be conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and risk of bias will be done according to the Integrated quality Criteria for Review of Multiple Study Designs. ETHICS AND DISSEMINATION Our findings will be presented to clinicians and policymakers, to support developing AMS protocols for low resource settings. We will publish our results in peer-reviewed journals. TRIAL REGISTRATION NUMBER CRD42020210634.
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Affiliation(s)
- Grace Wezi Mzumara
- Child Health, Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Chichiri, Blantyre 3 Malawi, Malawi
- Peadiatrics and Child Health, University of Malawi College of Medicine, Chichiri, Blantyre 3 Malawi, Malawi
| | - Michael Mambiya
- Child Health, Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Chichiri, Blantyre 3 Malawi, Malawi
| | - Pui-Ying Iroh Tam
- Child Health, Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Chichiri, Blantyre 3 Malawi, Malawi
- Peadiatrics and Child Health, University of Malawi College of Medicine, Chichiri, Blantyre 3 Malawi, Malawi
- Liverpool School of Tropical Medicine, Liverpool, UK
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Okeah BO, Morrison V, Huws JC. Antimicrobial stewardship and infection prevention interventions targeting healthcare-associated Clostridioides difficile and carbapenem-resistant Klebsiella pneumoniae infections: a scoping review. BMJ Open 2021; 11:e051983. [PMID: 34348956 PMCID: PMC8340296 DOI: 10.1136/bmjopen-2021-051983] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 07/23/2021] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES This study assessed antimicrobial stewardship (AMS) and infection prevention (IP) interventions targeting healthcare-associated Clostridioides difficile and carbapenem-resistant Klebsiella pneumoniae (CRKP) infections, their key outcomes and the application of behaviour change principles in these interventions. DESIGN This scoping review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analysis Extension for Scoping Reviews (PRISMA-ScR) guidelines while focusing on acute healthcare settings in both low-to-middle income and high-income countries. DATA SOURCES The databases searched were MEDLINE, PubMed, Web of Science and CINAHL between 22 April 2020 and 30 September 2020. ELIGIBILITY The review included peer-reviewed articles published in English language between 2010 and 2019. Studies that focussed on IP and/or AMS interventions primarily targeting C. difficile or CRKP were included. Studies that assessed effectiveness of diagnostic devices or treatment options were excluded from this review. DATA EXTRACTION AND SYNTHESIS An abstraction sheet calibrated for this study was used to extract data on the main study characteristics including the population, intervention and outcomes of interest (antimicrobial use, compliance with IP interventions and risk for C. difficile and CRKP). A narrative synthesis of the results is provided. RESULTS The review included 34 studies. Analysis indicates that interventions targeting C. difficile and CRKP include Education, Surveillance/Screening, Consultations, Audits, Policies and Protocols, Environmental measures, Bundles, Isolation as well as Notifications or alerts (represented using the ESCAPE-BIN acronym). The identified outcomes include antimicrobial use, resistance rates, risk reduction, adherence to contact precautions, hospital stay and time savings. AMS and IP interventions tend to be more adhoc with limited application of behaviour change principles. CONCLUSION This scoping review identified the AMS and IP interventions targeting C. difficile and CRKP in healthcare settings and described their key outcomes. The application of behaviour change principles in AMS and IP interventions appears to be limited.
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Affiliation(s)
| | | | - Jaci C Huws
- School of Medical & Health Sciences, Bangor University, Bangor, UK
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Wojcik G, Ring N, McCulloch C, Willis DS, Williams B, Kydonaki K. Understanding the complexities of antibiotic prescribing behaviour in acute hospitals: a systematic review and meta-ethnography. ACTA ACUST UNITED AC 2021; 79:134. [PMID: 34301332 PMCID: PMC8299683 DOI: 10.1186/s13690-021-00624-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 05/30/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND Antimicrobial resistance poses a serious global public health threat. Hospital misuse of antibiotics has contributed to this problem and evidence-based interventions are urgently needed to change inappropriate prescribing practices. This paper reports the first theoretical stage of a longer-term project to improve antibiotic prescribing in hospitals through design of an effective behaviour-change intervention. METHODS Qualitative synthesis using meta-ethnography of primary studies reporting doctors' views and experiences of antibiotic prescribing in hospitals for example, their barriers to appropriate prescribing. Twenty electronic databases were systematically searched over a 10-year period and potential studies screened against eligibility criteria. Included studies were quality-appraised. Original participant quotes and author interpretations were extracted and coded thematically into NVivo. All study processes were conducted by two reviewers working independently with findings discussed with the wider team and key stakeholders. Studies were related by findings into clusters and translated reciprocally and refutationally to develop a new line-of-argument synthesis and conceptual model. Findings are reported using eMERGe guidance. RESULTS Fifteen papers (13 studies) conducted between 2007 and 2017 reporting the experiences of 336 doctors of varying seniority working in acute hospitals across seven countries, were synthesised. Study findings related in four ways which collectively represented multiple challenges to appropriate antibiotic medical prescribing in hospitals: loss of ownership of prescribing decisions, tension between individual care and public health concerns, evidence-based practice versus bedside medicine, and diverse priorities between different clinical teams. The resulting new line-of-argument and conceptual model reflected how these challenges operated on both micro- and macro-level, highlighting key areas for improving current prescribing practice, such as creating feedback mechanisms, normalising input from other specialties and reducing variation in responsibility for antibiotic decisions. CONCLUSIONS This first meta-ethnography of doctors` experiences of antibiotic prescribing in acute hospital settings has enabled development of a novel conceptual model enhancing understanding of appropriate antibiotic prescribing. That is, hospital antibiotic prescribing is a complex, context-dependent and dynamic process, entailing the balancing of many tensions. To change practice, comprehensive efforts are needed to manage failures in communication and information provision, promote distribution of responsibility for antibiotic decisions, and reduce fear of consequences from not prescribing. TRIAL REGISTRATION PROSPERO registration: CRD42017073740 .
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Affiliation(s)
- Gosha Wojcik
- School of Health and Social Care, Edinburgh Napier University, EH11 4BN, Edinburgh, UK.
| | - Nicola Ring
- School of Health and Social Care, Edinburgh Napier University, EH11 4BN, Edinburgh, UK
| | - Corrienne McCulloch
- Edinburgh Critical Care Research Group, University of Edinburgh, Edinburgh Royal Infirmary, EH16 4SA, Edinburgh, UK
| | - Diane S Willis
- School of Health and Social Care, Edinburgh Napier University, EH11 4BN, Edinburgh, UK
| | - Brian Williams
- School of Health and Social Care, Edinburgh Napier University, EH11 4BN, Edinburgh, UK
| | - Kalliopi Kydonaki
- School of Health and Social Care, Edinburgh Napier University, EH11 4BN, Edinburgh, UK
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Kallen MC, Hulscher MEJL, Elzer B, Geerlings SE, van der Linden PD, Teerenstra S, Natsch S, Opmeer BC, Prins JM. A multicentre cluster-randomized clinical trial to improve antibiotic use and reduce length of stay in hospitals: comparison of three measurement and feedback methods. J Antimicrob Chemother 2021; 76:1625-1632. [PMID: 33638644 PMCID: PMC8120330 DOI: 10.1093/jac/dkab035] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 01/20/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Various metrics of hospital antibiotic use might assist in guiding antimicrobial stewardship (AMS). OBJECTIVES To compare patient outcomes in association with three methods to measure and feedback information on hospital antibiotic use when used in developing an AMS intervention. METHODS Three methods were randomly allocated to 42 clusters from 21 Dutch hospitals: (1) feedback on quantity of antibiotic use [DDD, days-of-therapy (DOT) from hospital pharmacy data], versus feedback on (2) validated, or (3) non-validated quality indicators from point prevalence studies. Using this feedback together with an implementation tool, stewardship teams systematically developed and performed improvement strategies. The hospital length of stay (LOS) was the primary outcome and secondary outcomes included DOT, ICU stay and hospital mortality. Data were collected before (February-May 2015) and after (February-May 2017) the intervention period. RESULTS The geometric mean hospital LOS decreased from 9.5 days (95% CI 8.9-10.1, 4245 patients) at baseline to 9.0 days (95% CI 8.5-9.6, 4195 patients) after intervention (P < 0.001). No differences in effect on LOS or secondary outcomes were found between methods. Feedback on quality of antibiotic use was used more often to identify improvement targets and was preferred over feedback on quantity of use. Consistent use of the implementation tool seemed to increase effectiveness of the AMS intervention. CONCLUSIONS The decrease in LOS versus baseline likely reflects improvement in the quality of antibiotic use with the stewardship intervention. While the outcomes with the three methods were otherwise similar, stewardship teams preferred data on the quality over the quantity of antibiotic use.
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Affiliation(s)
- M C Kallen
- Amsterdam UMC, University of Amsterdam, Department of Internal Medicine, Division of Infectious Diseases, Meibergdreef 9, Amsterdam, The Netherlands
| | - M E J L Hulscher
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Geert Grooteplein Zuid 10, Nijmegen, The Netherlands
| | - B Elzer
- Amsterdam UMC, University of Amsterdam, Department of Internal Medicine, Division of Infectious Diseases, Meibergdreef 9, Amsterdam, The Netherlands
| | - S E Geerlings
- Amsterdam UMC, University of Amsterdam, Department of Internal Medicine, Division of Infectious Diseases, Meibergdreef 9, Amsterdam, The Netherlands
| | - P D van der Linden
- Tergooi Hospital, Department of Clinical Pharmacy, Van Riebeeckweg 212, Hilversum, The Netherlands
| | - S Teerenstra
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department for Health Evidence, Group Biostatistics, Geert Grooteplein Zuid 10, Nijmegen, The Netherlands
| | - S Natsch
- Radboud University Medical Center, Department of Pharmacy, Geert Grooteplein Zuid 10, Nijmegen, The Netherlands
| | - B C Opmeer
- Amsterdam UMC, University of Amsterdam, Clinical Research Unit, Meibergdreef 9, Amsterdam, The Netherlands
| | - J M Prins
- Amsterdam UMC, University of Amsterdam, Department of Internal Medicine, Division of Infectious Diseases, Meibergdreef 9, Amsterdam, The Netherlands
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van den Broek AK, Beishuizen BHH, Haak EAF, Duyvendak M, Ten Oever J, Sytsma C, van Triest M, Wielders CCH, Prins JM. A mandatory indication-registration tool in hospital electronic medical records enabling systematic evaluation and benchmarking of the quality of antimicrobial use: a feasibility study. Antimicrob Resist Infect Control 2021; 10:103. [PMID: 34217361 PMCID: PMC8254448 DOI: 10.1186/s13756-021-00973-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 06/18/2021] [Indexed: 12/20/2022] Open
Abstract
Objectives Evaluation of the extent and appropriateness of antimicrobial use is a cornerstone of antibiotic stewardship programs, but it is time-consuming. Documentation of the indication at the moment of prescription might be more time-efficient. We investigated the real-life feasibility of mandatory documentation of the indication for all hospital antibiotic prescriptions for quality evaluation purposes. Methods A mandatory prescription-indication format was implemented in the Electronic Medical Record (EMR) of three hospitals using EPIC or ChipSoft HIX software. We evaluated the retrieved data of all antibiotics (J01) prescribed as empiric therapy in adult patients with respiratory tract infections (RTI) or urinary tract infections (UTI), from January through December 2017 in Hospital A, June through October 2019 in Hospital B and May 2019 through June 2020 in Hospital C. Endpoints were the accuracy of the data, defined as agreement between selected indication for the prescription and the documented indication in the EMR, as assessed by manually screening a representative sample of eligible patient records in the EMR of the three hospitals, and appropriateness of the prescriptions, defined as the prescriptions being in accordance with the national guidelines. Results The datasets of hospitals A, B and C contained 9588, 338 and 5816 empiric antibiotic prescriptions indicated for RTI or UTI, respectively. The selected indication was in accordance with the documented indication in 96.7% (error rate: 10/300), 78.2% (error rate: 53/243), and 86.9% (error rate: 39/298), respectively. A considerable variation in guideline adherence was seen between the hospitals for severe community acquired pneumonia (adherence rate ranged from 35.4 to 53.0%), complicated UTI (40.0–67.1%) and cystitis (5.6–45.3%). Conclusions After local validation of the datasets to verify and optimize accuracy of the data, mandatory documentation of the indication for antibiotics enables a reliable and time-efficient method for systematic registration of the extent and appropriateness of empiric antimicrobial use, which might enable benchmarking both in-hospital and between hospitals. Supplementary Information The online version contains supplementary material available at 10.1186/s13756-021-00973-0.
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Affiliation(s)
- Annemieke K van den Broek
- Division of Infectious Diseases, Department of Internal Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Berend H H Beishuizen
- Center for Infectious Disease Control, National Institute for Public Health and the Environment, Antonie van Leeuwenhoeklaan 9, 3721 MA, Bilthoven, The Netherlands
| | - Eric A F Haak
- Department of Hospital Pharmacy, OLVG, Location Oost, Oosterpark 9, 1091 AC, Amsterdam, The Netherlands
| | - Michiel Duyvendak
- Department of Hospital Pharmacy, Antonius Hospital, Location Sneek, Bolswarderbaan 1, 8601 ZK, Sneek, The Netherlands
| | - Jaap Ten Oever
- Department of Internal Medicine, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - Chris Sytsma
- Department of Information Technology, Antonius Hospital, Location Sneek, Bolswarderbaan 1, 8601 ZK, Sneek, The Netherlands
| | - Mieke van Triest
- Center for Infectious Disease Control, National Institute for Public Health and the Environment, Antonie van Leeuwenhoeklaan 9, 3721 MA, Bilthoven, The Netherlands
| | - Cornelia C H Wielders
- Center for Infectious Disease Control, National Institute for Public Health and the Environment, Antonie van Leeuwenhoeklaan 9, 3721 MA, Bilthoven, The Netherlands
| | - Jan M Prins
- Division of Infectious Diseases, Department of Internal Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
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de Wilde SP, Buijtels PCAM, Jong E, Nagtegaal EJ. Gentamicin associated nephrotoxicity under antibiotic stewardship program handling. Infect Dis (Lond) 2021; 53:959-962. [PMID: 34162305 DOI: 10.1080/23744235.2021.1941240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Affiliation(s)
- Sofieke P de Wilde
- Department Hospital Pharmacy, Meander Medical Center, Amersfoort, The Netherlands
| | | | - Eefje Jong
- Department of Internal Medicine, Meander Medical Center, Amersfoort, The Netherlands
| | - Elsbeth J Nagtegaal
- Department Hospital Pharmacy, Meander Medical Center, Amersfoort, The Netherlands
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Belan M, Thilly N, Pulcini C. Antimicrobial stewardship programmes in nursing homes: a systematic review and inventory of tools. J Antimicrob Chemother 2021; 75:1390-1397. [PMID: 32108883 DOI: 10.1093/jac/dkaa013] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 01/05/2020] [Accepted: 01/07/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Antimicrobial overuse/misuse is common in nursing homes and although the effectiveness of antimicrobial stewardship (AMS) programmes has been well explored and demonstrated in hospitals, data are scarce for the nursing-home setting. Our objectives for this systematic review were to make an inventory of: (i) all interventions that could be considered as part of AMS programmes in nursing homes; and (ii) all stewardship tools and guidance that are freely available. METHODS We performed a systematic review using the MEDLINE database from inception to June 2018, including all interventional studies, reviews, opinion pieces and guidelines/guidance exploring AMS programmes in nursing homes. For the inventory of freely available tools and guidance to help implement an AMS programme, we also performed screening of professional societies and official agencies' websites and a questionnaire survey among a panel of international experts. RESULTS A total of 36 articles were included in our systematic review. Most interventions took place in North America and have explored education or persuasive interventions within multifaceted interventions, showing that they can improve guideline adherence and decrease antibiotic use and unnecessary microbiological testing. Most reviews also highlighted the importance of accountability, monitoring and feedback. A large number of tools (156) available for free on the internet were identified, mostly about education, patient assessment and outcome measurement. CONCLUSIONS Although high-quality interventional studies are lacking, multifaceted interventions including education, monitoring and feedback seem the most promising strategy. Many tools are available on the internet and can be used to help implement AMS programmes in nursing homes.
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Affiliation(s)
- Martin Belan
- Université de Lorraine, CHRU-Nancy, Département de maladies infectieuses, Nancy, France
| | - Nathalie Thilly
- Université de Lorraine, APEMAC, Nancy, France.,Université de Lorraine, CHRU-Nancy, Département Méthodologie Promotion Investigation, Nancy, France
| | - Céline Pulcini
- Université de Lorraine, CHRU-Nancy, Département de maladies infectieuses, Nancy, France.,Université de Lorraine, APEMAC, Nancy, France
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Talkhan H, Stewart D, Mcintosh T, Ziglam H, Abdulrouf PV, Al-Hail M, Diab M, Cunningham S. The use of theory in the development and evaluation of behaviour change interventions to improve antimicrobial prescribing: a systematic review. J Antimicrob Chemother 2021; 75:2394-2410. [PMID: 32356877 DOI: 10.1093/jac/dkaa154] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 03/06/2020] [Accepted: 03/27/2020] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES This systematic review (SR) reviews the evidence on use of theory in developing and evaluating behaviour change interventions (BCIs) to improve clinicians' antimicrobial prescribing (AP). METHODS The SR protocol was registered with PROSPERO. Eleven databases were searched from inception to October 2018 for peer-reviewed, English-language, primary literature in any healthcare setting and for any medical condition. This included research on changing behavioural intentions (e.g. in simulated scenarios) and research measuring actual AP. All study designs/methodologies were included. Excluded were: grey literature and/or those which did not state a theory. Two reviewers independently extracted and quality assessed the data. The Theory Coding Scheme (TCS) evaluated the extent of the use of theory. RESULTS Searches found 4227 potentially relevant papers after removal of duplicates. Screening of titles/abstracts led to dual assessment of 38 full-text papers. Ten (five quantitative, three qualitative and two mixed-methods) met the inclusion criteria. Studies were conducted in the UK (n = 8), Canada (n = 1) and Sweden (n = 1), most in primary care settings (n = 9), targeting respiratory tract infections (n = 8), and medical doctors (n = 10). The most common theories used were Theory of Planned Behaviour (n = 7), Social Cognitive Theory (n = 5) and Operant Learning Theory (n = 5). The use of theory to inform the design and choice of intervention varied, with no optimal use as recommended in the TCS. CONCLUSIONS This SR is the first to investigate theoretically based BCIs around AP. Few studies were identified; most were suboptimal in theory use. There is a need to consider how theory is used and reported and the systematic use of the TCS could help.
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Affiliation(s)
- Hend Talkhan
- School of Pharmacy and Life Sciences, Robert Gordon University, Aberdeen, UK
| | - Derek Stewart
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar
| | - Trudi Mcintosh
- School of Pharmacy and Life Sciences, Robert Gordon University, Aberdeen, UK
| | - Hisham Ziglam
- Infectious Diseases Department, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | | | - Moza Al-Hail
- Pharmacy Department, Women's Wellness and Research Center, Hamad Medical Corporation, Doha, Qatar
| | - Mohammad Diab
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar
| | - Scott Cunningham
- School of Pharmacy and Life Sciences, Robert Gordon University, Aberdeen, UK
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Schiek S, Ranft D, Truckenbrod C, Dürrbeck A, Chaberny I, Rodloff A, Lübbert C, Bertsche T. [Antibiotics Stewardship Team Recommendations - An Analysis under Routine Conditions in a University Hospital]. DAS GESUNDHEITSWESEN 2021; 84:503-509. [PMID: 33915578 DOI: 10.1055/a-1471-5311] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
AIM To evaluate recommendations of an antibiotic stewardship (ABS) team during routine weekly visits and to analyse their implementation and reasons for non-implementation by the ward physicians. METHODS Multiprofessional ABS Rounds (members: infectiology, microbiology, pharmacy and hospital epidemiology) were accompanied by an observer in nine intensive and peripheral wards of a university hospital (1451 beds) for eight weeks. The recommendations of the ABS team were prospectively analysed, and when these were not implemented, ward physicians in charge were asked to give reasons for non-implementation. RESULTS A total of 262 patients were visited in the course of 359 ABS visits. A median of four physicians and one pharmacist (Q25/Q75: 4/6) participated in the ABS rounds. In 177/359 (49%) of visits, at least one recommendation for anti-infective therapy was given; the total number of recommendations made was 210. The most frequent (38%, 80/210) recommendations were related to the prescribed therapy duration. The more different the professional groups participating in the ABS rounds, the larger was the number of recommendations given (p=0.016; odds ratio=1.018 (1.003-1.033)). 62/210 (30%) of the ABS recommendations were not implemented by the ward physicians in charge. The most frequent reason (32%: 20/62) for this was the deliberate decision by the physicians to deviate from the recommended therapy. CONCLUSIONS The high recommendation rate of 50% demonstrates the need for optimizing therapy by the ABS teams in routine practice. The larger the number of different specialists participating in single visits, the larger was the number of recommendations. Reasons for the lack of implementations need to be critically examined by both the ABS team and the ward physicians in charge.
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Affiliation(s)
- Susanne Schiek
- Abteilung für Klinische Pharmazie, Institut für Pharmazie, Medizinische Fakultät, Universität Leipzig, Leipzig, Deutschland.,Zentrum für Arzneimittelsicherheit, Universität und Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Donald Ranft
- Zentrum für Arzneimittelsicherheit, Universität und Universitätsklinikum Leipzig, Leipzig, Deutschland.,Apotheke, Universitätsklinikum Leipzig, Leipzig, Deutschland.,Interdisziplinäres Zentrum für Infektionsmedizin, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Clemens Truckenbrod
- Abteilung für Klinische Pharmazie, Institut für Pharmazie, Medizinische Fakultät, Universität Leipzig, Leipzig, Deutschland.,Zentrum für Arzneimittelsicherheit, Universität und Universitätsklinikum Leipzig, Leipzig, Deutschland.,Apotheke, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Axel Dürrbeck
- Zentrum für Arzneimittelsicherheit, Universität und Universitätsklinikum Leipzig, Leipzig, Deutschland.,Apotheke, Universitätsklinikum Leipzig, Leipzig, Deutschland.,Interdisziplinäres Zentrum für Infektionsmedizin, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Iris Chaberny
- Institut für Hygiene, Krankenhaushygiene und Umweltmedizin, Universitatsklinikum Leipzig, Leipzig, Deutschland
| | - Arne Rodloff
- Interdisziplinäres Zentrum für Infektionsmedizin, Universitätsklinikum Leipzig, Leipzig, Deutschland.,Institut für Medizinische Mikrobiologie und Infektionsepidemiologie, Universitatsklinikum Leipzig, Leipzig, Deutschland
| | - Christoph Lübbert
- Interdisziplinäres Zentrum für Infektionsmedizin, Universitätsklinikum Leipzig, Leipzig, Deutschland.,Bereich Infektiologie und Tropenmedizin, Medizinische Klinik 2 (Onkologie, Gastroenterologie, Hepatologie, Pneumologie und Infektiologie), Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Thilo Bertsche
- Interdisziplinäres Zentrum für Infektionsmedizin, Universitätsklinikum Leipzig, Leipzig, Deutschland.,Bereich Infektiologie und Tropenmedizin, Medizinische Klinik 2 (Onkologie, Gastroenterologie, Hepatologie, Pneumologie und Infektiologie), Universitätsklinikum Leipzig, Leipzig, Deutschland
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36
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Chan AJ, O'Donnell D, Kaasa B, Mathers A, Papaioannou A, Brazil K, Paraschiv N, Goldstein M, Sadowski CA, Dolovich L. Barriers and facilitators of implementing an antimicrobial stewardship intervention for urinary tract infection in a long-term care facility. Can Pharm J (Ott) 2021; 154:100-109. [PMID: 33868521 DOI: 10.1177/1715163521989756] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Fifty percent of antibiotic courses in long-term care facilities (LTCFs) are unnecessary, leading to increased risk of harm. Most studies to improve antibiotic prescribing in LTCFs showed modest and unsustained results. We aimed to identify facilitators, barriers and strategies in implementing a urinary tract infection (UTI)-focused antimicrobial stewardship (AS) intervention at a LTCF, with the secondary objective of exploring the pharmacist's potential roles. Methods The study used a qualitative descriptive design. Participants attended either a focus group or one-on-one interview. Data were analyzed inductively using a codebook modified in an iterative analytic process. Barrier and facilitator themes were mapped using the capability, opportunity, motivation and behaviour (COM-B) model. Similarly, themes were identified from the transcripts regarding the pharmacist's roles. Results Sixteen participants were interviewed. Most barriers and facilitators mapped to the opportunities domain of the COM-B model. The main barrier themes were lack of access, lack of knowledge, ineffective communication, lack of resources and external factors, while the main facilitator themes were education, effective collaboration, good communication, sufficient resources and access. For the pharmacist's role, the barrier themes were ineffective collaboration and communication. Conclusion This study supports the importance of tailoring interventions to target factors underlying barriers to behaviour change. At this LTCF, an effective antimicrobial stewardship intervention should incorporate strategies to improve access, knowledge, communication and collaboration in its design, having sufficient resources and addressing external factors to optimize its success and long-term sustainability. Can Pharm J (Ott) 2021;154:xx-xx.
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37
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Badia JM, Batlle M, Juvany M, Ruiz-de León P, Sagalés M, Pulido MA, Molist G, Cuquet J. Surgeon-led 7-VINCut Antibiotic Stewardship Intervention Decreases Duration of Treatment and Carbapenem Use in a General Surgery Service. Antibiotics (Basel) 2020; 10:antibiotics10010011. [PMID: 33374393 PMCID: PMC7823351 DOI: 10.3390/antibiotics10010011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 12/16/2020] [Accepted: 12/23/2020] [Indexed: 12/13/2022] Open
Abstract
Antibiotic stewardship programs optimize the use of antimicrobials to prevent the development of resistance and improve patient outcomes. In this prospective interventional study, a multidisciplinary team led by surgeons implemented a program aimed at shortening the duration of antibiotic treatment <7 days. The impact of the intervention on antibiotic consumption adjusted to bed-days and discharges, and the isolation of multiresistant bacteria (MRB) was also studied. Furthermore, the surgeons were surveyed regarding their beliefs and feelings about the program. Out of 1409 patients, 40.7% received antibiotic therapy. Treatment continued for over 7 days in 21.5% of cases, and, as can be expected, source control was achieved in only 48.8% of these cases. The recommendations were followed in 90.2% of cases, the most frequent being to withdraw the treatment (55.6%). During the first 16 months of the intervention, a sharp decrease in the percentage of extended treatments, with R2 = 0.111 was observed. The program was very well accepted by surgeons, and achieved a decrease in both the consumption of carbapenems and in the number of MRB isolations. Multidisciplinary stewardship teams led by surgeons seem to be well received and able to better manage antibiotic prescription in surgery.
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Affiliation(s)
- Josep M. Badia
- Department of Surgery, Hospital General Granollers, Universitat Internacional de Catalunya, 08402 Granollers, Spain; (M.B.); (M.J.); (P.R.-d.L.)
- Correspondence: or ; Tel.: +34-670702099
| | - Maria Batlle
- Department of Surgery, Hospital General Granollers, Universitat Internacional de Catalunya, 08402 Granollers, Spain; (M.B.); (M.J.); (P.R.-d.L.)
| | - Montserrat Juvany
- Department of Surgery, Hospital General Granollers, Universitat Internacional de Catalunya, 08402 Granollers, Spain; (M.B.); (M.J.); (P.R.-d.L.)
| | - Patricia Ruiz-de León
- Department of Surgery, Hospital General Granollers, Universitat Internacional de Catalunya, 08402 Granollers, Spain; (M.B.); (M.J.); (P.R.-d.L.)
| | - Maria Sagalés
- Department of Clinical Pharmacy, Hospital General Granollers, 08402 Granollers, Spain;
| | - M Angeles Pulido
- Department of Clinical Microbiology, Hospital General Granollers, 08402 Granollers, Spain;
| | - Gemma Molist
- Department of Statistics and Research, Hospital General Granollers, 08402 Granollers, Spain;
| | - Jordi Cuquet
- Infectious Diseases Unit, Hospital General Granollers, 08402 Granollers, Spain;
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Abstract
TOPIC Microbial organisms include bacteria, viruses, fungi, and parasites. Antimicrobial medications are currently overused or misused, which has resulted in multidrug resistance. Hospitalized patients in the intensive care unit have the highest risk for infections leading to poor outcomes and require successful treatment options. CLINICAL RELEVANCE Inappropriate prescription of antimicrobials places patients and the community at risk for more resistant infections in the future. To prevent misapplication of these important medications, interdisciplinary antimicrobial stewardship programs promote appropriate and safe antimicrobial medication use. Members of these programs are called to be good stewards of antimicrobial medications, incorporating the scope of practice and knowledge of each specialty and the evidence from the literature to develop strategies and protocols for safe and effective antimicrobial medication use. PURPOSE OF PAPER Nurse involvement in antimicrobial stewardship programs is inadequate, limiting the programs' potential. Support for increased direct-care nurse participation in antimicrobial stewardship programs is key to improve program targets and patient outcomes. CONTENT COVERED This article calls for increased nursing awareness of the importance of antimicrobial stewardship programs in clinical practice and greater direct-care nurse involvement in these programs.
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Affiliation(s)
- Allison M L Sloan
- Allison M. L. Sloan is an acute care nurse practitioner in the cardiovascular intensive care unit at J. W. Ruby Memorial Hospital, Morgantown, West Virginia
| | - Linda Dudjak
- Linda Dudjak is an adjunct associate professor at the University of Pittsburgh School of Nursing, Pennsylvania
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Kahlmeter G, Thilly N, Pulcini C. Selective reporting of antibiotic susceptibility testing results: less is more. Clin Microbiol Infect 2020; 27:503-505. [PMID: 33253937 DOI: 10.1016/j.cmi.2020.11.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 11/15/2020] [Accepted: 11/19/2020] [Indexed: 12/18/2022]
Affiliation(s)
- Gunnar Kahlmeter
- Department of Clinical Microbiology, Central Hospital, Växjö, Sweden; EUCAST Development Laboratory, Växjö, Sweden
| | - Nathalie Thilly
- Université de Lorraine, APEMAC, Nancy, France; Université de Lorraine, CHRU-Nancy, Département Méthodologie, Promotion et Investigation, Nancy, France
| | - Céline Pulcini
- Université de Lorraine, APEMAC, Nancy, France; Université de Lorraine, CHRU-Nancy, Département de Maladies Infectieuses et Tropicales, Nancy, France.
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40
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Quality indicators for appropriate antimicrobial therapy in the emergency department: a pragmatic Delphi procedure. Clin Microbiol Infect 2020; 27:210-214. [PMID: 33144204 DOI: 10.1016/j.cmi.2020.10.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 10/24/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Antimicrobial stewardship (AMS) has established its importance for inpatient care. AMS is, however, also urgently needed in emergency departments (ED), where many antimicrobial prescriptions are initiated. It is currently unclear what metrics stewardship teams can use to measure and improve the appropriateness of antimicrobial prescription in the ED. In this study we develop quality indicators (QIs) for antimicrobial use in the ED. METHODS A RAND-modified Delphi procedure was used to develop a set of QIs applicable to adult patients who present at the ED with a potential infection. First, pragmatically using two recent papers of the international expert-group DRIVE-AB, potential ED-specific QIs for appropriate antimicrobial use were retrieved. Thereafter, an international multidisciplinary expert panel appraised these QIs during two questionnaire rounds with a meeting in between. RESULTS Thirty-three potential QIs were extracted from the DRIVE-AB papers. After appraisal by 13 experts, 22 QIs describing appropriate antimicrobial use in the ED were selected. These indicators provide recommendations within five domains: stewardship prerequisites (six QIs); diagnostics (one QI); empirical treatment (ten QIs); documentation of information (four QIs); and patient discharge (one QI). CONCLUSIONS We pragmatically developed a set of 22 QIs that can be used by stewardship teams to measure the appropriateness of antimicrobial prescription in the ED. There is probably room for additional QI development to cover all key aspects of AMS in the ED. Measuring QIs can be a first step for stewardship teams to, in collaboration with ED professionals, choose targets for improvement and optimize antimicrobial use.
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May L, Martín Quirós A, Ten Oever J, Hoogerwerf J, Schoffelen T, Schouten J. Antimicrobial stewardship in the emergency department: characteristics and evidence for effectiveness of interventions. Clin Microbiol Infect 2020; 27:204-209. [PMID: 33144202 DOI: 10.1016/j.cmi.2020.10.028] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 10/21/2020] [Accepted: 10/24/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Emergency departments (EDs) are the entrance gates for patients presenting with infectious diseases into the hospital, yet most antimicrobial stewardship programmes are primarily focused on inpatient management. With equally high rates of inappropriate antibiotic use, the ED is a frequently overlooked yet important unit for targeted antimicrobial stewardship (AMS) interventions. OBJECTIVES We aimed to (a) describe the specific aspects of antimicrobial stewardship in the ED and (b) summarize the findings from improvement studies that have investigated the effectiveness of antimicrobial stewardship interventions in the ED setting. SOURCES (a) a PubMed search for 'antimicrobial stewardship' and 'emergency department', and (b) published reviews on effectiveness combined with publications from the first source. CONTENT (a) An in depth analysis of selected publications provided four key antimicrobial use processes typically performed by front-line healthcare professionals in the ED: making a (tentative) clinical diagnosis, starting empirical therapy based on that diagnosis, performing microbiological tests before starting that therapy and following up patients who are discharged from the ED. (b) Further, we discuss the literature on improvement strategies in the ED focusing on guidelines and clinical pathways and multifaceted improvement strategies. We also summarize the evidence of microbiologic culture review. IMPLICATIONS Based on our review of the literature, we describe four essential elements of antimicrobial use in the ED. Studying the various interventions targeting these care processes, we have found them to be of a variable degree of success. Nonetheless, while there is a paucity of AS studies specifically targeting the ED, there is a growing body of evidence that AS programmes in the ED are effective with modifications to the ED setting. We present key questions for future research.
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Affiliation(s)
- Larissa May
- Department of Emergency Medicine, University of California Davis, Sacramento, CA, USA
| | | | - Jaap Ten Oever
- Department of Internal Medicine, Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jacobien Hoogerwerf
- Department of Internal Medicine, Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Teske Schoffelen
- Department of Internal Medicine, Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jeroen Schouten
- Scientific Center for Quality of Healthcare (IQ Healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands; Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, the Netherlands.
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Karami Z, Knoop BT, Dofferhoff ASM, Blaauw MJT, Janssen NA, van Apeldoorn M, Kerckhoffs APM, van de Maat JS, Hoogerwerf JJ, Ten Oever J. Few bacterial co-infections but frequent empiric antibiotic use in the early phase of hospitalized patients with COVID-19: results from a multicentre retrospective cohort study in The Netherlands. Infect Dis (Lond) 2020; 53:102-110. [PMID: 33103530 DOI: 10.1080/23744235.2020.1839672] [Citation(s) in RCA: 97] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Knowledge on bacterial co-infections in COVID-19 is crucial to use antibiotics appropriately. Therefore, we aimed to determine the incidence of bacterial co-infections, antibiotic use and application of antimicrobial stewardship principles in hospitalized patients with COVID-19. METHODS We performed a retrospective observational study in four hospitals (1 university, 2 non-university teaching, 1 non-teaching hospital) in the Netherlands from March to May 2020 including consecutive patients with PCR-confirmed COVID-19. Data on first microbiological investigations obtained at the discretion of the physician and antibiotic use in the first week of hospital admission were collected. RESULTS Twelve (1.2%) of the 925 patients included had a documented bacterial co-infection (75.0% pneumonia) within the first week. Microbiological testing was performed in 749 (81%) patients: sputum cultures in 105 (11.4%), blood cultures in 711 (76.9%), pneumococcal urinary antigen testing in 202 (21.8%), and Legionella urinary antigen testing in 199 (21.5%) patients, with clear variation between hospitals. On presentation 556 (60.1%; range 33.3-73.4%) patients received antibiotics for a median duration of 2 days (IQR 1-4). Intravenous to oral switch was performed in 41 of 413 (9.9%) patients who received intravenous treatment >48 h. Mean adherence to the local guideline on empiric antibiotic therapy on day 1 was on average 60.3% (range 45.3%-74.7%). CONCLUSIONS On presentation to the hospital bacterial co-infections are rare, while empiric antibiotic use is abundant. This implies that in patients with COVID-19 empiric antibiotic should be withheld. This has the potential to dramatically reduce the current overuse of antibiotics in the COVID-19 pandemic.
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Affiliation(s)
- Zara Karami
- Radboud University Medical Center, Nijmegen, The Netherlands.,Radboud Center for Infectious diseases, Nijmegen, The Netherlands
| | - Bram T Knoop
- Radboud University Medical Center, Nijmegen, The Netherlands.,Radboud Center for Infectious diseases, Nijmegen, The Netherlands
| | | | - Marc J T Blaauw
- Radboud University Medical Center, Nijmegen, The Netherlands.,Radboud Center for Infectious diseases, Nijmegen, The Netherlands.,Canisius Wilhelmina Ziekenhuis, Nijmegen, The Netherlands.,Bernhoven University, Uden, The Netherlands
| | - Nico A Janssen
- Radboud University Medical Center, Nijmegen, The Netherlands.,Radboud Center for Infectious diseases, Nijmegen, The Netherlands
| | | | | | - Josephine S van de Maat
- Radboud University Medical Center, Nijmegen, The Netherlands.,Radboud Center for Infectious diseases, Nijmegen, The Netherlands
| | - Jacobien J Hoogerwerf
- Radboud University Medical Center, Nijmegen, The Netherlands.,Radboud Center for Infectious diseases, Nijmegen, The Netherlands
| | - Jaap Ten Oever
- Radboud University Medical Center, Nijmegen, The Netherlands.,Radboud Center for Infectious diseases, Nijmegen, The Netherlands
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43
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Graham DY. Transitioning of Helicobacter pylori Therapy from Trial and Error to Antimicrobial Stewardship. Antibiotics (Basel) 2020; 9:E671. [PMID: 33023041 PMCID: PMC7601139 DOI: 10.3390/antibiotics9100671] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 09/28/2020] [Accepted: 10/01/2020] [Indexed: 12/21/2022] Open
Abstract
Helicobacter pylori is the only major infection for which antimicrobial therapy is not designed using the principles of antimicrobial stewardship. Traditionally, antimicrobial therapy is a susceptibility-based therapy, achieves high cure rates, and includes surveillance programs to regularly provide updated data regarding resistance, outcomes, and treatment guidelines. Current H. pylori therapies identified by trial-and-error, and treatment recommendations and guidelines are based on comparisons among regimens that rarely take into account the prevalence or effect of resistance. The majority of patients currently treated achieve suboptimal results. A paradigm shift is required to abandon current approaches and embrace antimicrobial stewardship, and therefore reliably achieve high cure rates; develop, propagate, and update best practice guidelines; and provide surveillance of local or regional susceptibility/resistance patterns. These also require timely updates to clinicians regarding the current status of resistance, antimicrobial effectiveness, and ways to prevent antimicrobial misuse to extend the useful life of currently available antibiotics. Here, we discuss the differences among current approaches to H. pylori therapy and antimicrobial stewardship and identify what is required to achieve the transition. Conceptually, the differences are significant, and the transition will likely need to be both abrupt and complete. Recommendations for therapy during the transition period are given.
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Affiliation(s)
- David Y Graham
- Department of Medicine, Michael E. DeBakey VA Medical Center and Baylor College of Medicine, RM 3A-318B (111D), 2002 Holcombe Boulevard, Houston, TX 77030, USA
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44
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Wallenburg E, ter Heine R, Schouten JA, Brüggemann RJ. Personalised antimicrobial dosing: standing on the shoulders of giants. Int J Antimicrob Agents 2020; 56:106062. [DOI: 10.1016/j.ijantimicag.2020.106062] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 06/02/2020] [Accepted: 06/13/2020] [Indexed: 12/17/2022]
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45
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Exploring barriers to and enablers of antimicrobial stewardship in rural health services. Infect Dis Health 2020; 26:11-21. [PMID: 32868207 DOI: 10.1016/j.idh.2020.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 07/27/2020] [Accepted: 08/04/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND World-wide antimicrobial resistance is increasing, and antimicrobial stewardship (AMS) interventions aimed at increasing compliance with optimal antimicrobial prescribing are essential in tackling this issue. Local level research about antimicrobial use is important to tailor interventions in a place-based approach to solve local level problems. METHODS As part of a broader mixed methods study, Medical Practitioners and Senior Nurses at three rural health services were invited by email to participate in interviews to explore opinions and practices of antimicrobial prescribing. RESULTS Seven Medical Practitioners and thirteen Senior Nurses from three small rural health services participated in the study. The major findings were that nurses were perceived as the 'gatekeepers' to antimicrobial initiatives by all participants. Senior Nurses perceived AMS activities as being a link in a world-wide program to eradicate antimicrobial resistance, while Medical Practitioners perceived it as a local level program, aimed at educating individual prescribers. There was consensus that an intervention aimed at improved documentation at the point of prescribing and increased accessibility to antimicrobial prescribing guidelines had a high potential for increased compliance with optimal prescribing of antimicrobials. CONCLUSION The research enabled identification of interventions aimed at increasing optimal compliance with antimicrobial prescribing that are acceptable to and appropriate for Medical Practitioners and nursing staff at three rural health services.
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46
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Perozziello A, Lescure FX, Truel A, Routelous C, Vaillant L, Yazdanpanah Y, Lucet JC. Prescribers' experience and opinions on antimicrobial stewardship programmes in hospitals: a French nationwide survey. J Antimicrob Chemother 2020; 74:2451-2458. [PMID: 31167027 DOI: 10.1093/jac/dkz179] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 03/19/2019] [Accepted: 04/04/2019] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVES To assess prescribers' experiences and opinions regarding antimicrobial stewardship programme (ASP) activities. METHODS A cross-sectional paper-based survey was conducted among prescribers in 27 out of 35 randomly selected large hospitals in France. RESULTS All 27 investigated hospitals (20 non-university public, 4 university-affiliated and 3 private hospitals) had an ASP and an appointed antibiotic advisor (AA), with a median of 0.9 full-time equivalents per 1000 acute-care beds (IQR 0-1.4). Of the 1963 distributed questionnaires, 920 were completed (46.9%). Respondents were mainly attending physicians (658/918, 71.7%) and medical specialists (532/868, 61.3%). Prescribers identified two main ASP objectives: to limit the spread of resistance (710/913, 77.8%) and to improve patient care and prognosis (695/913, 76.1%). The presence of an AA constituted a core element of ASP (96.2% agreement between answers of ASP leader and respondents). Respondents acknowledged an AA's usefulness especially on therapeutic issues, i.e. choosing appropriate antibiotic (agreement 84.7%) or adapting treatment (89.6%), but less so on diagnostic issues (31.4%). Very few respondents reported unsolicited counselling and post-prescription controls. Three-quarters of prescribers identified local guidelines (692/918, 75.4%). Prescribers did not approve of measures counteracting their autonomy, i.e. automatic stop orders (agreement 23.4%) or pre-approval by AAs (28.8%). They agreed more with educational interventions (73.0%) and clinical staff meetings (70.0%). CONCLUSIONS Prescribers perceived ASP mainly through its 'on-demand' counselling activities. They preferred measures that did not challenge their clinical autonomy. High levels of antibiotic consumption in French hospitals bring into question the effectiveness of such an approach. However, limited ASP staffing and resources may preclude extended activities.
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Affiliation(s)
- A Perozziello
- IAME, UMR 1137, DeSCID team, Université Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - F X 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
| | - A Truel
- IAME, UMR 1137, DeSCID team, Université Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - C 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
| | - L Vaillant
- UHLIN, Hôpital Bichat-Claude Bernard, AP-HP, Paris, France
| | - Y 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
| | - J C Lucet
- IAME, UMR 1137, DeSCID team, Université Paris Diderot, Sorbonne Paris Cité, Paris, France.,UHLIN, Hôpital Bichat-Claude Bernard, AP-HP, Paris, France
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47
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Christensen I, Haug JB, Berild D, Bjørnholt JV, Jelsness-Jørgensen LP. Hospital physicians' experiences with procalcitonin - implications for antimicrobial stewardship; a qualitative study. BMC Infect Dis 2020; 20:515. [PMID: 32677903 PMCID: PMC7364625 DOI: 10.1186/s12879-020-05246-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 07/10/2020] [Indexed: 12/03/2022] Open
Abstract
Background Procalcitonin is an inflammatory biomarker that is sensitive for bacterial infections and a promising clinical decision aid in antimicrobial stewardship programs. However, there are few studies of physicians’ experiences concerning the use of PCT. The objective of this study was to investigate whether hospital physicians’ experience with procalcitonin after 18 months of use can inform the PCT implementation in antimicrobial stewardship programs. Materials/methods We deployed a qualitative approach using semi-structured interviews with 14 hospital physicians who had experience with procalcitonin in clinical practice. Interviews were audio-taped, transcribed verbatim and analysed using thematic analysis. Results Physicians reported a knowledge gap, which made them uncertain about the appropriate procalcitonin use, interpretation, and trustworthiness. Simultaneously, the physicians experienced procalcitonin as a useful clinical decision aid but emphasised that their clinical evaluation of the patient was the most important factor when deciding on antibiotic treatment. Conclusions Procalcitonin was regarded a helpful clinical tool, but the physicians called for more knowledge about its appropriate uses. Active implementation of unambiguous procalcitonin algorithms and physician education may enhance the utility of the test as an antimicrobial stewardship adjunct.
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Affiliation(s)
- Ingrid Christensen
- Department of INFECTION Control, Østfold Hospital Trust, Kalnes, Norway. .,Faculty of Medicine, University of Oslo, PhD Program Medicine and Health Sciences, Oslo, Norway.
| | - Jon Birger Haug
- Department of INFECTION Control, Østfold Hospital Trust, Kalnes, Norway
| | - Dag Berild
- Department of Infectious Diseases, Oslo University Hospital, Oslo, Norway.,Oslo University, Faculty of Medicine, Institute of Clinical Medicine, Oslo, Norway
| | - Jørgen Vildershøj Bjørnholt
- Oslo University, Faculty of Medicine, Institute of Clinical Medicine, Oslo, Norway.,Department of Microbiology, Oslo University Hospital, Oslo, Norway
| | - Lars-Petter Jelsness-Jørgensen
- Faculty of Health and Social Studies, Østfold University College, Fredrikstad, Norway.,Department of Science, Østfold Hospital Trust, Kalnes, Norway
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Donisi V, Sibani M, Carrara E, Del Piccolo L, Rimondini M, Mazzaferri F, Bovo C, Tacconelli E. Emotional, cognitive and social factors of antimicrobial prescribing: can antimicrobial stewardship intervention be effective without addressing psycho-social factors? J Antimicrob Chemother 2020; 74:2844-2847. [PMID: 31299072 DOI: 10.1093/jac/dkz308] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
There is increasing evidence that psycho-social factors can influence antimicrobial prescribing practice in hospitals and the community, and represent potential barriers to antimicrobial stewardship interventions. Clinicians are conditioned both by emotional and cognitive factors based on fear, uncertainty, a set of beliefs, risk perception and cognitive bias, and by interpersonal factors established through social norms and peer and doctor-patient communication. However, a gap is emerging between research and practice, and no stewardship recommendation addresses the most appropriate human resource allocation or modalities to account for psycho-social determinants of prescribing. There is a need for translation of the evidence available from human behaviour studies to the design and implementation of stewardship interventions and policies at hospital and community levels. The integration of behaviour experts into multidisciplinary stewardship teams seems essential to positively impact on prescribers' communication and decision-making competencies, and reduce inappropriate antibiotic prescribing.
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Affiliation(s)
- V Donisi
- Clinical Psychology, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy.,Infectious Disease, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - M Sibani
- Infectious Disease, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - E Carrara
- Infectious Disease, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - L Del Piccolo
- Clinical Psychology, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - M Rimondini
- Clinical Psychology, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - F Mazzaferri
- Infectious Disease, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - C Bovo
- Medical Direction, University Hospital of Verona, Verona, Italy
| | - E Tacconelli
- Infectious Disease, Department of Diagnostics and Public Health, University of Verona, Verona, Italy.,Infectious Diseases, Department of Internal Medicine I, Tübingen University, Tübingen, Germany
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49
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Paiva JA, Mergulhão P, Salluh JIF. What every intensivist must know about antimicrobial stewardship: its pitfalls and its challenges. Rev Bras Ter Intensiva 2020; 32:207-212. [PMID: 32667443 PMCID: PMC7405748 DOI: 10.5935/0103-507x.20200037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Accepted: 11/04/2019] [Indexed: 11/29/2022] Open
Affiliation(s)
- José-Artur Paiva
- Departamento de Medicina Intensiva, Centro Hospitalar Universitário São João, Porto, Portugal
| | - Paulo Mergulhão
- Departamento de Medicina Intensiva, Centro Hospitalar Universitário São João, Porto, Portugal
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50
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Rzewuska M, Duncan EM, Francis JJ, Morris AM, Suh KN, Davey PG, Grimshaw JM, Ramsay CR. Barriers and Facilitators to Implementation of Antibiotic Stewardship Programmes in Hospitals in Developed Countries: Insights From Transnational Studies. FRONTIERS IN SOCIOLOGY 2020; 5:41. [PMID: 33869448 PMCID: PMC8022532 DOI: 10.3389/fsoc.2020.00041] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 05/12/2020] [Indexed: 06/12/2023]
Abstract
Objectives: To identify perceived influences on implementation of antibiotic stewardship programmes (ASPs) in hospitals, across healthcare systems, and to exemplify the use of a behavioral framework to conceptualize those influences. Methods: EMBASE and MEDLINE databases were searched from 01/2001 to 07/2017 and reference lists were screened for transnational studies that reported barriers and/or facilitators to implementing actual or hypothetical ASPs or ASP-supporting strategies. Extracted data were synthesized using content analysis with the Theoretical Domains Framework as an organizing framework. Commonly reported influences were quantified. Results: From 3,196 abstracts 75 full-text articles were screened for inclusion. Eight studies met the eligibility criteria. The number of countries involved in each study ranged from 2 to 36. These studies included a total of 1849 participants. North America, Europe and Australasia had the strongest representation. Participants were members of special interest groups, designated hospital representatives or clinical experts. Ten of the 14 theoretical domains in the framework were present in the results reported in the included studies. The most commonly reported (≥4 out of 8 studies) influences on ASP implementation were coded in the domain "environmental context and resources" (e.g., problems with data and information systems; lack of key personnel; inadequate financial resources) and "goals" (other higher priorities). Conclusions: Despite an extensive transnational research effort, there is evidence from international studies of substantial barriers to implementing ASPs in hospitals, even in developed countries. Large-scale efforts to implement hospital antibiotic stewardship in those countries will need to overcome issues around inadequacy of information systems, unavailability of key personnel and funding, and the competition from other priority initiatives. We have enhanced the evidence base to inform guidance by taking a behavioral approach to identify influences on ASP uptake. Systematic review registration: PROSPERO registration number CRD42017076425.
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Affiliation(s)
- Magdalena Rzewuska
- Health Services Research Unit, University of Aberdeen, Aberdeen, United Kingdom
| | - Eilidh M. Duncan
- Health Services Research Unit, University of Aberdeen, Aberdeen, United Kingdom
| | - Jill J. Francis
- School of Health Sciences, City University of London, London, United Kingdom
| | - Andrew M. Morris
- Department of Medicine, Sinai Health System and University Health Network, Toronto, ON, Canada
- Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Kathryn N. Suh
- Department of Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Peter G. Davey
- Division of Population Health & Genomics, Medical School, University of Dundee, Dundee, United Kingdom
| | - Jeremy M. Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Craig R. Ramsay
- Health Services Research Unit, University of Aberdeen, Aberdeen, United Kingdom
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