Barriers to uptake of antimicrobial advice in a UK hospital: a qualitative study

Nurses' attitudes, behaviours, and enablers of intravenous to oral switching (IVOS) of antibiotics: a mixed-methods survey of nursing staff in secondary care hospitals across the Midlands region of England

BACKGROUND

Intravenous (IV) antibiotic use in secondary care in England is widespread. Timely appropriate intravenous to oral switch (IVOS) has the potential to deliver significant clinical and operational benefits. To date, antimicrobial stewardship (AMS) efforts around IVOS have not focused on the nursing staff who administer antibiotics, which represents a significant gap in AMS programmes.

AIM

To determine the involvement of bedside nurses in acute trusts in the Midlands region of England in IVOS in their organizations and describe their views regarding how to improve IVOS.

METHODS

An anonymous self-administered mixed-methods online survey was developed and distributed to nursing staff in acute trusts via antimicrobial stewardship networks between March and May 2023. Quantitative data was analysed to describe participant demographics and behaviours, whereas barriers and enablers to IVOS were explored through thematic content analysis of responses to open-ended questions.

FINDINGS

A total of 545 nursing staff responded to the survey. The majority (65.3%) routinely suggested IVOS to clinicians, despite only 50.6% being aware of local IVOS policies. One-third (34.7%) did not suggest IVOS, relying on doctors, believing their patients needed IV treatment, or lacked knowledge and skills to request IVOS. Content analysis of suggestions for improving the rate of IVOS proposed three major themes (People, Process, System) and identified that education and training, improved confidence and interprofessional relationships, and prompts were important drivers.

CONCLUSION

Nursing staff suggest IVOS to other clinicians, but more education and resources are needed to enable and empower them in this role.

Public hospital pharmacists' knowledge, attitudes, and practices for antibiotic stewardship implementation in Limpopo Province, South Africa

BACKGROUND

Hospital pharmacists are important in antibiotic stewardship programs (ASP), a global strategy to combat antibiotic resistance (ABR). South African public hospitals have limited ASP implementation. This study describes Limpopo Provincial Hospital pharmacists' knowledge, attitudes, and practice toward ASP implementation.

METHOD

A questionnaire to explore pharmacists' knowledge, attitudes and practices regarding ASP implementation comprised 43 questions hosted online. A link was sent by invitation e-mail to eligible respondents in November 2021. Five questions on respondents' demographics, 15 questions on ASP knowledge, 10 Likert scale questions on attitude, and 13 on ASP practices were included. Mean (standard deviation (SD)) knowledge and attitude scores and a median (interquartile range (IQR)) practice score was calculated. Associations between categorical variables were assessed using chi-square/Fisher's exact analysis (p < 0.05), with Cramér's V as effect size.

RESULTS

The survey yielded 35 responses (13.1%). Twenty (57.1%) respondents were female. Seventeen (48.6%) respondents were between the ages of 31 and 40 years. The mean knowledge score of respondents was 9.8 (2.6) (N = 34), with knowledge gaps on One Health and socioeconomic determinates of ABR. Ten (29.6%) respondents thought One Health discouraged multi-sector collaboration, and nineteen (55.9%) respondents thought ASP was the only strategic response to ABR. Sixteen (47.1%) respondents did not know that poor access to clean water accelerates ABR and seventeen (50.0%) did not know that poverty could be a determinant for antibiotic use. The mean respondent attitude score was 8.0 (1.7) (N = 28). Twenty-seven (96.4%) respondents agreed that ASP was necessary and agreed to participate in ASP respectively. All 28 (100.0%) respondents agreed to lead an ASP. The median (IQR) respondents' practice score was - 2.0 (IQR: -6.0-5.8) (N = 16). Respondents were inconsistently (never, sometimes, every time) participating in multi-disciplinary forums (6/16, 37.5%) and expressed a desire for training (11/13, 84.6%) on ASP through in-service (7/27, 25.9%). Respondents thought ASP training should include medical officers (12/29, 41.4%) and nurses (9/29, 31.8%). Knowledge score was associated with gender (p = 0.048; V = 0.416) and attitude score (p = 0.013; V = 0.556).

CONCLUSION

Our study found pharmacists had good knowledge and a positive attitude toward ASP implementation but poor ASP practices. A multi-disciplinary in-service training could address identified knowledge and practice gaps.

A qualitative evaluation of frontline clinician perspectives toward antibiotic stewardship programs

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.

Rationale and clinical application of antimicrobial stewardship principles in the intensive care unit: a multidisciplinary statement

BACKGROUND

Antimicrobial resistance represents a major critical issue for the management of the critically ill patients hospitalized in the intensive care unit (ICU), since infections by multidrug-resistant bacteria are characterized by high morbidity and mortality, high rates of treatment failure, and increased healthcare costs worldwide. It is also well known that antimicrobial resistance can emerge as a result of inadequate antimicrobial therapy, in terms of drug selection and/or treatment duration. The application of antimicrobial stewardship principles in ICUs improves the quality of antimicrobial therapy management. However, it needs specific considerations related to the critical setting.

METHODS

The aim of this consensus document gathering a multidisciplinary panel of experts was to discuss principles of antimicrobial stewardship in ICU and to produce statements that facilitate their clinical application and optimize their effectiveness. The methodology used was a modified nominal group discussion.

CONCLUSION

The final set of statements underlined the importance of the specific interpretation of antimicrobial stewardship's principles in critically ill patient management, quasi-targeted therapy, the use of rapid diagnostic methods, the personalization of antimicrobial therapies' duration, obtaining microbiological surveillance data, the use of PK/PD targets, and the use of specific indicators in antimicrobial stewardship programs.

Association between self-reported evidence-based medicine competencies and prescribing of drugs without scientific evidence against mild COVID-19 among recently graduated physicians in Peru

Objective

To evaluate the association between self-rated evidence-based medicine (EBM) competencies and the prescription of drugs without scientific evidence against mild COVID-19 (present with any of the signs and symptoms of COVID-19 but who do not have shortness of breath, dyspnea, or abnormal chest imaging) among recently graduated physicians in Peru.

Methods

We conducted an analytical cross-sectional study where we evaluated a non-probability sample of recently graduated physicians during June and July 2021 (end of second wave of COVID-19 in Peru). Self-rated EBM competencies were assessed by four domains (formulation of a clinical question, search, analysis, and application) using a Likert scale with scores from zero to four ("Very inadequate" = 0, to "Very Adequate" = 4), it was considered as "Adequate" if the score was three or four. In addition, the variable "General competence on EBM" was rated as "Adequate" if in all domains evaluated it presented an adequate self-rating. For the outcome, drug prescription, we considered the use of ivermectin, azithromycin, other antibiotics, hydroxychloroquine, dexamethasone, and anticoagulants (drugs with no efficacy demonstrated for patients with mild COVID-19). To assess the association, we used Poisson regression models with robust variances and obtaining crude (cPR) and adjusted (aPR) prevalence ratios with their 95% confidence intervals (95%CI).

Results

Of a total of 239 physicians included 70.7% prescribed at least one drug without scientific evidence. A total of 51.1% reported adequate ratings in all evaluated domains of EBM. Self-rating the "Clinical Question Formulation" competency as adequate was associated with a lower frequency of prescribing medications for mild COVID-19 (aPR: 0.93; 95% CI: 0.91-0.95). While self-rating as adequate the competency of "Identify possible implications of investigations" was associated with an increase in the prescription of such drugs (aPR: 1.14; 95% CI: 1.09-1.20). Additionally, self-rating all domains as adequate were associated with less prescription (aPR: 0.93; 95% CI: 0.90-0.96).

Conclusion

Seven out of ten recently graduated physicians prescribed some type of medication without scientific evidence to treat patients with mild COVID-19. Having adequate self-perceived EBM competencies was associated with a lower frequency of prescribing medications without scientific evidence to manage patients with mild COVID-19.

Mixed-methods process evaluation of a respiratory-culture diagnostic stewardship intervention

OBJECTIVE

To conduct a process evaluation of a respiratory culture diagnostic stewardship intervention.

DESIGN

Mixed-methods study.

SETTING

Tertiary-care pediatric intensive care unit (PICU).

PARTICIPANTS

Critical care, infectious diseases, and pulmonary attending physicians and fellows; PICU nurse practitioners and hospitalist physicians; pediatric residents; and PICU nurses and respiratory therapists.

METHODS

This mixed-methods study was conducted concurrently with a diagnostic stewardship intervention to reduce the inappropriate collection of respiratory cultures in mechanically ventilated children. We quantified baseline respiratory culture utilization and indications for ordering using quantitative methods. Semistructured interviews informed by these data and the Consolidated Framework for Implementation Research (CFIR) were then performed, recorded, transcribed, and coded to identify salient themes. Finally, themes identified in these interviews were used to create a cross-sectional survey.

RESULTS

The number of cultures collected per day of service varied between attending physicians (range, 2.2-27 cultures per 100 days). In total, 14 interviews were performed, and 87 clinicians completed the survey (response rate, 47%) and 77 nurses or respiratory therapists completed the survey (response rate, 17%). Clinicians varied in their stated practices regarding culture ordering, and these differences both clustered by specialty and were associated with perceived utility of the respiratory culture. Furthermore, group "default" practices, fear, and hierarchy were drivers of culture orders. Barriers to standardization included fear of a missed diagnosis and tension between practice standardization and individual decision making.

CONCLUSIONS

We identified significant variation in utilization and perceptions of respiratory cultures as well as several key barriers to implementation of this diagnostic test stewardship intervention.

Taking the route less traveled: on the way to COpAT

Antimicrobial therapy is an essential practice within medicine. Over the last 4 years, complex outpatient antimicrobial therapy (COpAT) with oral antimicrobials has become a rapidly developing area of practice and is non-inferior to outpatient parenteral antimicrobial therapy (OPAT) in certain infectious syndromes. Currently, the available literature does not describe the implementation of oral antimicrobials within the current outpatient antimicrobial therapy process. Throughout this article, the authors present a review of current literature, a proposed definition of COpAT and offer methods readers can utilize to implement an integrated COpAT/OPAT program with oral antimicrobial-specific monitoring within their current practice.

Nurses' and Physicians' Responses to a New Active Antimicrobial Stewardship Program: A Two-Phase Study of Responses and Their Underlying Perceptions and Values

BACKGROUND

Successful implementation of an antimicrobial stewardship program (ASP) depends on staff members' response to it. We introduced at the Hadassah Medical Center in Israel a significant change to our long-standing handshake ASP. As before, the new ASP involved a dialogue between the treating physician and the infectious disease physician over the appropriate antibiotic therapy. The main change was that the infectious disease physician's decision was now integrated into the patient's electronic medical record (EMR). Our purpose in this study was to uncover the concerns and expectations of physicians and nurses towards the new ASP, before and after its implementation, and link these with their basic perceptions of the ASP and their personal values.

METHODS

We used open-ended questions and Likert-type scales to study staff members' personal values, basic perceptions of the new system, and attitudes towards it, both before (N = 143), and one year after (N = 103) the system's implementation. Relationships of the system's perceptions and personal values with attitudes toward the system were tested using correlations and multiple regression analyses.

RESULTS

Prior to its implementation, physicians and nurses had multiple concerns about the new ASP's demandingness and inefficiency and its threat to physicians' autonomy and expertise. They also had positive expectations for benefits to the hospital, the patients and society. A year later, following the system's implementation, concerns dissipated, whereas the perceived benefits remained. Moreover, staff members' attitudes tended to be more positive among those who value conformity.

CONCLUSION

Introducing new ASPs is a challenging process. Our findings suggest that hospital staff's initial concerns about the new ASP were primarily about its ease of use and demandingness. These concerns, which diminished over time, were linked with perceived satisfaction with the system. Conformity values had an indirect effect in predicting satisfaction with the system, mediated by perceptions of the system as straightforward.

Eligibility for and Use of Oral Antimicrobial Therapy Among Veterans With Osteoarticular Infections: A Retrospective Study Across 8 Medical Centers

We retrospectively evaluated antimicrobial therapy in 145 randomly selected patients with osteoarticular infections across 8 hospitals. One hundred nine (75%) were eligible for oral antimicrobial therapy, but only 18 received it: 5 of 39 (13%) in 2018 versus 13 of 70 (19%) in 2019-2020 (P = .44). Oral antimicrobials may be underutilized for osteoarticular infections in routine practice.

Exploring unintended consequences of adult antimicrobial stewardship programs: An Emerging Infections Network survey

We performed a survey of adult infectious diseases (ID) physicians to explore unintended consequences of antimicrobial stewardship programs (ASP). ID physicians worried about disagreement with colleagues, provider autonomy, and remote recommendations. Non-ASP ID physicians expressed more concern regarding ASPs focus on costs, provider efficiency, and unintended consequences of ASP guidance.

An implementation framework and a feasibility evaluation of a clinical decision support system for diabetes management in secondary mental healthcare using CogStack

BACKGROUND

Improvements to the primary prevention of physical health illnesses like diabetes in the general population have not been mirrored to the same extent in people with serious mental illness (SMI). This work evaluates the technical feasibility of implementing an electronic clinical decision support system (eCDSS) for supporting the management of dysglycaemia and diabetes in patients with serious mental illness in a secondary mental healthcare setting.

METHODS

A stepwise approach was taken as an overarching and guiding framework for this work. Participatory methods were employed to design and deploy a monitoring and alerting eCDSS. The eCDSS was evaluated for its technical feasibility. The initial part of the feasibility evaluation was conducted in an outpatient community mental health team. Thereafter, the evaluation of the eCDSS progressed to a more in-depth in silico validation.

RESULTS

A digital health intervention that enables monitoring and alerting of at-risk patients based on an approved diabetes management guideline was developed. The eCDSS generated alerts according to expected standards and in line with clinical guideline recommendations.

CONCLUSIONS

It is feasible to design and deploy a functional monitoring and alerting eCDSS in secondary mental healthcare. Further work is required in order to fully evaluate the integration of the eCDSS into routine clinical workflows. By describing and sharing the steps that were and will be taken from concept to clinical testing, useful insights could be provided to teams that are interested in building similar digital health interventions.

What influences the implementation and sustainability of antibiotic stewardship programmes in hospitals? A qualitative study of antibiotic pharmacists' perspectives across South West England

OBJECTIVES

Antibiotic stewardship programmes (ASPs) are needed at every hospital as they can improve antibiotic use and address antibiotic resistance. Pharmacists are key agents and specialists in these programmes. This study explored antibiotic pharmacists' perceptions of factors that influence the implementation and sustainability of hospital-based ASPs.

METHODS

Semistructured interviews were conducted with hospital antibiotic pharmacists face-to-face or by telephone. NVivo V.12 software was used to collate and organise the data grouped within codes. Thematic analysis was undertaken using inductive and deductive approaches to produce overarching themes.

RESULTS

Thirteen pharmacists from 13 hospitals were interviewed. Four main themes were identified: (1) 'organisational culture' which highlighted the importance of strong local clinical leadership to help achieve organisational buy-in and address resistance among physicians or clinical hierarchies; (2) 'national influences' including networks, guidance and incentive schemes which were considered to be a driver to bring about changes across organisation; (3) 'continuous monitoring with feedback ASP data, preferably through direct communication' to demonstrate the impact of the programmes which then facilitated ongoing support from local leadership and improved engagement across organisation; and (4) 'resources' which indicated the need of information technology and dedicated personnel with protected time to support ASP activities.

CONCLUSIONS

Interventions and strategies should operate at different levels-individual, team, organisational and national-to help implement and sustain ASPs in hospital. This is also the first study to identify and highlight the importance of national initiatives in contributing to the implementation and sustainability of hospital-based ASPs.

Institutional governance and responsiveness to antimicrobial resistance: a qualitative study of Australian hospital executives

OBJECTIVES

Despite escalating antimicrobial resistance (AMR), implementing effective antimicrobial optimisation within healthcare settings has been hampered by institutional impediments. This study sought to examine, from a hospital management and governance perspective, why healthcare providers may find it challenging to enact changes needed to address rising AMR.

DESIGN

Semistructured qualitative interviews around their experiences of antimicrobial stewardship (AMS) and responsiveness to the requirement for optimisation. Data were analysed using the framework approach.

SETTING

Two metropolitan tertiary-referral hospitals in Australia.

PARTICIPANTS

Twenty hospital managers and executives from the organisational level of department head and above, spanning a range of professional backgrounds and in both clinical and non-clinical roles, and different professional streams were represented.

RESULTS

Thematic analysis demonstrated three key domains which managers and executives describe, and which might function to delimit institutional responsiveness to present and future AMR solutions. First, the primacy of 'political' priorities. AMR was perceived as a secondary priority, overshadowed by political priorities determined beyond the hospital by state health departments/ministries and election cycles. Second, the limits of accreditation as a mechanism for change. Hospital accreditation processes and regulatory structures were not sufficient to induce efficacious AMS. Third, a culture of acute problem 'solving' rather than future proofing. A culture of reactivity was described across government and healthcare institutions, precluding longer term objectives, like addressing the AMR crisis.

CONCLUSION

There are dynamics between political and health service institutions, as well as enduring governance norms, that may significantly shape capacity to enact AMS and respond to AMR. Until these issues are addressed, and the field moves beyond individual behaviour modification models, antimicrobial misuse will likely continue, and stewardship is likely to have a limited impact.

NO-HDAC dual inhibitors

HDAC inhibitors and NO donors have both demonstrated independently broad therapeutic potential in a variety of diseases. Borretto et al. presented the topic of NO-HDAC dual inhibitors for the first time in 2013 as an attractive new topic. Here we collected the general structure of all synthesized NO-HDAC dual inhibitors, lead compounds, synthesis methods and biological features of the most potent dual NO-HDAC inhibitor in each category with the intention of assisting in the synthesis and optimization of new drug-like compounds for diverse diseases. Based on studies done so far, NO-HDAC dual inhibitors have displayed satisfactory results against wound healing (3), heart hypertrophy (3), inflammatory, cardiovascular, neuromuscular illnesses (11a-11e) and cancer (6a-6o, 9a-9d, 10a-10d, 16 and 17). NO-HDAC dual inhibitors can have high therapeutic potential for various diseases due to their new properties, NO properties, HDAC inhibitor properties and also due to the effects of NO on HDAC enzymes.

Optimising antimicrobial use in humans - review of current evidence and an interdisciplinary consensus on key priorities for research

Addressing the silent pandemic of antimicrobial resistance (AMR) is a focus of the 2021 G7 meeting. A major driver of AMR and poor clinical outcomes is suboptimal antimicrobial use. Current research in AMR is inequitably focused on new drug development. To achieve antimicrobial security we need to balance AMR research efforts between development of new agents and strategies to preserve the efficacy and maximise effectiveness of existing agents. Combining a review of current evidence and multistage engagement with diverse international stakeholders (including those in healthcare, public health, research, patient advocacy and policy) we identified research priorities for optimising antimicrobial use in humans across four broad themes: policy and strategic planning; medicines management and prescribing systems; technology to optimise prescribing; and context, culture and behaviours. Sustainable progress depends on: developing economic and contextually appropriate interventions; facilitating better use of data and prescribing systems across healthcare settings; supporting appropriate and scalable technological innovation. Implementing this strategy for AMR research on the optimisation of antimicrobial use in humans could contribute to equitable global health security.

Understanding the complexities of antibiotic prescribing behaviour in acute hospitals: a systematic review and meta-ethnography

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 .

Pharmacist-led education-based antimicrobial stewardship interventions and their effect on antimicrobial use in hospital inpatients: a systematic review and narrative synthesis

BACKGROUND

Antimicrobial stewardship (AMS) programmes optimize antimicrobial use and address antimicrobial resistance. Pharmacists are often key agents of these programmes. The effectiveness of hospital-based AMS interventions when they are led by pharmacists, however, has not previously been reported.

AIM

To evaluate the effectiveness of pharmacist-led AMS interventions in improving antimicrobial use for hospital inpatients.

METHODS

Standard systematic review methods were used. The search strategies and databases used in a previous Cochrane review were applied. Studies that reported pharmacist-led AMS interventions were included. Narrative synthesis was used to report the findings. PRISMA guidelines were followed.

FINDINGS

From 6971 records retrieved and screened, 52 full-text articles were included. Most studies were undertaken in teaching hospitals (N = 45) and many were conducted in North America (N = 27). Most interventions targeted junior or ward physicians and lasted between one and six months. All studies evaluated educational interventions often in combination with other interventions and reported improvements 'in compliance with target AMS practice'. Greater compliance was achieved with multiple interventions. Pharmacist-led interventions reduced the duration of antimicrobial therapy without increasing mortality. No consistency of evidence was achieved in relation to interventions and reduced duration of hospital stay, nor infections due to antimicrobial resistance or occurrence of Clostridium difficile.

CONCLUSION

This is the first systematic review to evaluate the effectiveness of pharmacist-led AMS interventions in hospital inpatients. Education-based interventions were effective in increasing guideline compliance and reducing duration of antimicrobial therapy. Future hospital-based AMS programmes should consider the involvement of pharmacists to deliver and promote AMS interventions and programmes.

Understanding decisions about antibiotic prescribing in ICU: an application of the Necessity Concerns Framework

BACKGROUND

Antibiotics are extensively prescribed in intensive care units (ICUs), yet little is known about how antibiotic-related decisions are made in this setting. We explored how beliefs, perceptions and contextual factors influenced ICU clinicians' antibiotic prescribing.

METHODS

We conducted 4 focus groups and 34 semistructured interviews with clinicians involved in antibiotic prescribing in four English ICUs. Focus groups explored factors influencing prescribing, whereas interviews examined decision-making processes using two clinical vignettes. Data were analysed using thematic analysis, applying the Necessity Concerns Framework.

RESULTS

Clinicians' antibiotic decisions were influenced by their judgement of the necessity for prescribing/not prescribing, relative to their concerns about potential adverse consequences. Antibiotic necessity perceptions were strongly influenced by beliefs that antibiotics would protect patients from deterioration and themselves from the ethical and legal consequences of undertreatment. Clinicians also reported concerns about prescribing antibiotics. These generally centred on antimicrobial resistance; however, protecting the individual patient was prioritised over these societal concerns. Few participants identified antibiotic toxicity concerns as a key influencer. Clinical uncertainty often complicated balancing antibiotic necessity against concerns. Decisions to start or continue antibiotics often represented 'erring on the side of caution' as a protective response in uncertainty. This approach was reinforced by previous experiences of negative consequences ('being burnt') which motivated prescribing 'just in case' of an infection. Prescribing decisions were also context-dependent, exemplified by a lower perceived threshold to prescribe antibiotics out-of-hours, input from external team members and local prescribing norms.

CONCLUSION

Efforts to improve antibiotic stewardship should consider clinicians' desire to protect with a prescription. Rapid molecular microbiology, with appropriate communication, may diminish clinicians' fears of not prescribing or of using narrower-spectrum antibiotics.

Long-Term Sustainability and Acceptance of Antimicrobial Stewardship in Intensive Care: A Retrospective Cohort Study

OBJECTIVES

To evaluate long-term uptake of an antimicrobial stewardship audit-and-feedback program along with potential predictors of stewardship suggestions and acceptance across a diverse ICU population.

DESIGN

A retrospective cohort study.

SETTING

An urban, academic medical institution.

PATIENTS

Patients admitted to an ICU who received an antimicrobial stewardship program suggestion between June 2010 and September 2019.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

The antimicrobial stewardship program provided 7,749 antibiotic assessments over the study period and made a suggestion to alter therapy in 2,826 (36%). Factors associated with a higher likelihood of receiving a suggestion to alter therapy included shorter hospital length of stay prior to antimicrobial stewardship program review (odds ratio 1.15 for ≤ 5 d; 95% CI 1.00-1.32), admission to cardiovascular (1.37; 1.06-1.76) or burn surgery (1.88; 1.50-2.36) versus general medicine, and preceding duration of antibiotic use greater than 5 days (1.33; 1.10-1.60). Assessment of aminoglycosides (2.91; 1.85-4.89), carbapenems (1.93; 1.54-2.41), and vancomycin (2.71; 2.19-3.36) versus ceftriaxone was more likely to result in suggestions to alter therapy. The suggestion acceptance rate was 67% (1,895/2,826), which was stable throughout the study period. Admission to a level 3 ICU was associated with higher likelihood of acceptance of suggestions (1.50; 1.14-1.97). Factors associated with lower acceptance rates were admission to burn surgery (0.64; 0.45-0.91), treatment of pneumonia (0.64; 0.42-0.97 for community-acquired and 0.65; 0.44-0.94 for ventilator-acquired), unknown source of infection (0.66; 0.48-0.92), and suggestion types of "narrow spectrum" (0.65; 0.45-0.94), "change formulation of antibiotic" (0.42; 0.27-0.64), or "change agent of therapy" (0.63; 0.40-0.97) versus "change of dose".

CONCLUSIONS

An antimicrobial stewardship program implemented over a decade resulted in sustained suggestion and acceptance rates. These findings support the need for a persistent presence of audit-and-feedback over time with more frequent suggestions to alter potentially nephrotoxic agents, increased efforts toward specialized care units, and further work approaching infectious sources that are typically treated without pathogen confirmation and identification.

Perceived roles and barriers to nurses' engagement in antimicrobial stewardship: A Thai qualitative case study

BACKGROUND

Antimicrobial stewardship is the practice of ensuring the optimal use of antibiotics to prevent antimicrobial resistance. A multidisciplinary approach is considered best practice; however, little is known about nurses' contribution.

OBJECTIVES

To explore how organisational multidisciplinary leaders and clinical nurses perceive nurses' roles in AMS in a single organisational site case study based in Thailand, within the current governance, educational and practice context, and the barriers to nurses' engagement in AMS.

METHODS

A qualitative descriptive study using thematic analysis approach was conducted in a 1000-bed university hospital in Bangkok, Thailand. The combined number of organisational leaders and nurses was 33 including 15 individual organisational leader interviews and three focus groups involving 18 nurses.

RESULTS

Nurses currently participate in AMS by supporting system processes, monitoring safety and optimal antibiotic use and patient education. A lack of clear articulation of nurses' role and traditional professional hierarchies limits active participation. Inconsistent engagement was perceived as due to a failure to prioritise AMS activities, a lack of formal policies and a need for further education.

CONCLUSION

Nurses do engage in AMS but there are significant governance, hierarchical and educational impediments. These gaps need to be addressed before clearly defined nurse roles in AMS can be developed and embedded into clinical practice.

Barriers-enablers-ownership approach: a mixed methods analysis of a social intervention to improve surgical antibiotic prescribing in hospitals

OBJECTIVES

To assess an intervention for surgical antibiotic prophylaxis (SAP) improvement within surgical teams focused on addressing barriers and fostering enablers and ownership of guideline compliance.

DESIGN

The Queensland Surgical Antibiotic Prophylaxis (QSAP) study was a multicentre, mixed methods study designed to address barriers and enablers to SAP compliance and facilitate engagement in self-directed audit/feedback and assess the efficacy of the intervention in improving compliance with SAP guidelines. The implementation was assessed using a 24-month interrupted time series design coupled with a qualitative evaluation.

SETTING

The study was undertaken at three hospitals (one regional, two metropolitan) in Australia.

PARTICIPANTS

SAP-prescribing decisions for 1757 patients undergoing general surgical procedures from three health services were included. Six bimonthly time points, pre-implementation and post implementation of the intervention, were measured. Qualitative interviews were performed with 29 clinical team members. SAP improvements varied across site and time periods.

INTERVENTION

QSAP embedded ownership of quality improvement in SAP within surgical teams and used known social influences to address barriers to and enablers of optimal SAP prescribing.

RESULTS

The site that reported senior surgeon engagement showed steady and consistent improvement in prescribing over 24 months (prestudy and poststudy). Multiple factors, including resource issues, influenced engagement and sites/time points where these were present had no improvement in guideline compliance.

CONCLUSIONS

The barriers-enablers-ownership model shows promise in its ability to facilitate prescribing improvements and could be expanded into other areas of antimicrobial stewardship. Senior ownership was a predictor of success (or failure) of the intervention across sites and time periods. The key role of senior leaders in change leadership indicates the critical need to engage other specialties in the stewardship agenda. The influence of contextual factors in limiting engagement clearly identifies issues of resource distributions/inequalities within health systems as limiting antimicrobial optimisation potential.

Antibiotic Stewardship in the Intensive Care Unit. An Official American Thoracic Society Workshop Report in Collaboration with the AACN, CHEST, CDC, and SCCM

Intensive care units (ICUs) are an appropriate focus of antibiotic stewardship program efforts because a large proportion of any hospital’s use of parenteral antibiotics, especially broad-spectrum, occurs in the ICU. Given the importance of antibiotic stewardship for critically ill patients and the importance of critical care practitioners as the front line for antibiotic stewardship, a workshop was convened to specifically address barriers to antibiotic stewardship in the ICU and discuss tactics to overcome these. The working definition of antibiotic stewardship is “the right drug at the right time and the right dose for the right bug for the right duration.” A major emphasis was that antibiotic stewardship should be a core competency of critical care clinicians. Fear of pathogens that are not covered by empirical antibiotics is a major driver of excessively broad-spectrum therapy in critically ill patients. Better diagnostics and outcome data can address this fear and expand efforts to narrow or shorten therapy. Greater awareness of the substantial adverse effects of antibiotics should be emphasized and is an important counterargument to broad-spectrum therapy in individual low-risk patients. Optimal antibiotic stewardship should not focus solely on reducing antibiotic use or ensuring compliance with guidelines. Instead, it should enhance care both for individual patients (by improving and individualizing their choice of antibiotic) and for the ICU population as a whole. Opportunities for antibiotic stewardship in common ICU infections, including community- and hospital-acquired pneumonia and sepsis, are discussed. Intensivists can partner with antibiotic stewardship programs to address barriers and improve patient care.

Factors That Impact the Adoption of Clinical Decision Support Systems (CDSS) for Antibiotic Management

The study evaluated individual and setting-specific factors that moderate clinicians’ perception regarding use of clinical decision support systems (CDSS) for antibiotic management. A cross-sectional online survey examined clinicians’ perceptions about CDSS implementation for antibiotic management in Australia. Multivariable logistic regression determined the association between drivers of CDSS adoption and different moderators. Clinical experience, CDSS use and care setting were important predictors of clinicians’ perception concerning CDSS adoption. Compared to nonusers, CDSS users were less likely to lack confidence in CDSS (OR = 0.63, 95%, CI = 0.32, 0.94) and consider it a threat to professional autonomy (OR = 0.47, 95%, CI = 0.08, 0.83). Conversely, there was higher likelihood in experienced clinicians (>20 years) to distrust CDSS (OR = 1.58, 95%, CI = 1.08, 2.23) due to fear of comprising their clinical judgement (OR = 1.68, 95%, CI = 1.27, 2.85). In primary care, clinicians were more likely to perceive time constraints (OR = 1.96, 95%, CI = 1.04, 3.70) and patient preference (OR = 1.84, 95%, CI = 1.19, 2.78) as barriers to CDSS adoption for antibiotic prescribing. Our findings provide differentiated understanding of the CDSS implementation landscape by identifying different individual, organisational and system-level factors that influence system adoption. The individual and setting characteristics can help understand the variability in CDSS adoption for antibiotic management in different clinicians.

Antimicrobial overuse in India: A symptom of broader societal issues including resource limitations and financial pressures

India and the global community are facing a critical crisis of antimicrobial resistance (AMR), significantly contributed to by on-going and increasing antimicrobial misuse. Information as to what drives misuse of antimicrobials within India is essential to inform strategies to address the crisis. This papers aims to identify perceived influences on antimicrobial use in Hyderabad, India. We conducted semi-structured qualitative interviews conducted with thirty participants (15 doctors, 15 pharmacists) around their experiences of antimicrobials in Hyderabad, India. Thematic analysis was performed and four themes identified around (1) Perceptions of the problem of resistance and antimicrobial use; (2) Social pressures to prescribe/dispense; (3) Financial pressures driving antimicrobial over-use; and (4) Lack of regulation around training and qualifications. We conclude that antimicrobial use within India is embedded with, and occurs as a result of, complex social and economic factors including issues of resource limitation, structural/governance limitations and social relationships. Strategies to address misuse without acknowledging and addressing the critical driving forces of use will be unlikely to induce significant change.

Intervention planning for Antibiotic Review Kit (ARK): a digital and behavioural intervention to safely review and reduce antibiotic prescriptions in acute and general medicine

Background

Hospital antimicrobial stewardship strategies, such as ‘Start Smart, Then Focus’ in the UK, balance the need for prompt, effective antibiotic treatment with the need to limit antibiotic overuse using ‘review and revise’. However, only a minority of review decisions are to stop antibiotics. Research suggests that this is due to both behavioural and organizational factors.

Objectives

To develop and optimize the Antibiotic Review Kit (ARK) intervention. ARK is a complex digital, organizational and behavioural intervention that supports implementation of ‘review and revise’ to help healthcare professionals safely stop unnecessary antibiotics.

Methods

A theory-, evidence- and person-based approach was used to develop and optimize ARK and its implementation. This was done through iterative stakeholder consultation and in-depth qualitative research with doctors, nurses and pharmacists in UK hospitals. Barriers to and facilitators of the intervention and its implementation, and ways to address them, were identified and then used to inform the intervention’s development.

Results

A key barrier to stopping antibiotics was reportedly a lack of information about the original prescriber’s rationale for and their degree of certainty about the need for antibiotics. An integral component of ARK was the development and optimization of a Decision Aid and its implementation to increase transparency around initial prescribing decisions.

Conclusions

The key output of this research is a digital and behavioural intervention targeting important barriers to stopping antibiotics at review (see http://bsac-vle.com/ark-the-antibiotic-review-kit/ and http://antibioticreviewkit.org.uk/). ARK will be evaluated in a feasibility study and, if successful, a stepped-wedge cluster-randomized controlled trial at acute hospitals across the NHS.

Evaluation of a successful fluoroquinolone restriction intervention among high-risk patients: A mixed-methods study

OBJECTIVE

We conducted a quality improvement initiative to restrict fluoroquinolone prescribing on two inpatient units housing high-risk patients and applied a human factors approach to understanding the barriers and facilitators to success of this intervention by front-line providers.

METHODS

This was a mixed-methods, quasi-experimental study. This study was conducted on two inpatient units at a tertiary care academic medical center: the medical-surgical intensive care and abdominal solid organ transplant units. Unit-level data were collected retrospectively for 24 months pre- and post- fluoroquinolone restriction intervention, implemented in July 2016, for all admissions to the study units. Our restriction intervention required antimicrobial stewardship pre-approval for fluoroquinolone prescribing. We explored barriers and facilitators to optimal fluoroquinolone prescribing using semi-structured interviews attending, fellow and resident physicians, advanced practice providers and pharmacists on these units.

RESULTS

Hospital-onset C. difficile infection did not decrease significantly, but fluoroquinolone use declined significantly from 111.6 to 19.8 days of therapy per 1000 patient-days without negatively impacting length of stay, readmissions or mortality. Third generation cephalosporin and aminoglycoside use increased post-restriction. Providers identified our institution's strong antimicrobial stewardship program and pharmacy involvement in antimicrobial decision making as key facilitators of fluoroquinolone optimization and patient complexity, lack of provider education and organizational culture as barriers to optimal prescribing.

CONCLUSIONS

Fluoroquinolones can be safely restricted even among high-risk patients without negatively impacting length of stay, readmissions or mortality. Our study provides a framework for successful antimicrobial stewardship interventions informed by perceptions of front line providers.

The drivers of antimicrobial use across institutions, stakeholders and economic settings: a paradigm shift is required for effective optimization

OBJECTIVES

Significant antimicrobial overuse persists worldwide, despite overwhelming evidence of antimicrobial resistance and knowledge that optimization of antimicrobial use will slow the development of resistance. It is critical to understand why this occurs. This study aims to consider the social influences on antimicrobial use within hospitals in Australia, via an in-depth, multisite analysis.

METHODS

We used a qualitative multisite design, involving 222 individual semi-structured interviews and thematic analysis. Participants (85 doctors, 79 nurses, 31 pharmacists and 27 hospital managers) were recruited from five hospitals in Australia, including four public hospitals (two metropolitan, one regional and one remote) and one private hospital.

RESULTS

Analysis of the interviews identified social relationships and institutional structures that may have a strong influence on antimicrobial use, which must be addressed concurrently. (i) Social relationships that exist across settings: these include the influence of personal risk, hierarchies, inter- and intraprofessional dynamics and sense of futility in making a difference long term in relation to antimicrobial resistance. (ii) Institutional structures that offer context-specific influences: these include patient population factors (including socioeconomic factors, geographical isolation and local infection patterns), proximity and resource issues.

CONCLUSIONS

The success of antimicrobial optimization rests on adequate awareness and incorporation of multilevel influences. Analysis of the problem has tended to emphasize individual 'behaviour improvement' in prescribing rather than incorporating the problem of overuse as inherently multidimensional and necessarily incorporating personal, interpersonal and institutional variables. A paradigm shift is urgently needed to incorporate these critical factors in antimicrobial optimization strategies.

Prescribers' experience and opinions on antimicrobial stewardship programmes in hospitals: a French nationwide survey

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.

Perceptions of patients' and healthcare workers' experiences in cohort isolation units: a qualitative study

BACKGROUND

Given the scarce therapeutic options for carbapenemase-producing Enterobacterales (CPE), aggressive interventions are implemented to limit its spread among hospitalized patients. One such option is contact isolation by cohorting patients in designated units.

AIM

To describe the experiences in a cohort isolation unit (CIU) due to CPE from the perspectives of patients admitted to this unit and their families, and those of healthcare workers (HCWs) who served in the same unit.

METHODS

Qualitative study. Face-to-face, semi-structured interviews were conducted in a large tertiary hospital. Twenty-four participants were interviewed, including 15 HCWs, three patients and six family members. Data were coded using thematic analysis.

FINDINGS

The CIU provoked negative feelings such as fear, risk, loneliness, distrust and unfairness. They also created a sense of conflict with the curative assumptions of hospital care. The poor CIU infrastructure was echoed in perceptions of crowdedness in the site. Moreover, family members described HCWs' inconsistent protective behaviours that led them to a state of vigilance. The hospital infection control unit imparted and refreshed HCWs' knowledge and expected behaviours regarding the CIU. However, patients and families expressed dissatisfaction with the information, guidance and education regarding the 'why and how' of the CIU. They were not guided consistently about recommended behaviours after discharge. In retrospect, HCWs found that the CIU took a psychological, physical and professional toll.

CONCLUSION

The CIU was planned as a temporary containment mechanism. It needs to develop into a permanent system, capable of addressing the various needs of all involved.

Perspectives of Physician and Pharmacist Stewards on Successful Antibiotic Stewardship Program Implementation: A Qualitative Study

Background

Antibiotic stewardship programs (ASPs) are required at every hospital regardless of size. We conducted a qualitative study across different hospital settings to examine perspectives of physician and pharmacist stewards about the dynamics within their team and contextual factors that facilitate the success of their programs.

Methods

Semistructured interviews were conducted in March-November 2018 with 46 ASP stewards, 30 pharmacists, and 16 physicians, from 39 hospitals within 2 large hospital systems.

Results

We identified 5 major themes: antibiotic stewards were enthusiastic about their role, committed to the goals of stewardship for their patients and as a public-health imperative, and energized by successful interventions; responsibilities of pharmacist and physician stewards are markedly different, and pharmacy stewards performed the majority of the day-to-day stewardship work; collaborative teamwork is important to improving care, the pharmacists and physicians supported each other, and pharmacists believed that having a strong physician leader was essential; provider engagement strategies are a critical component of stewardship, and recommendations must be communicated in a collegial manner that did not judge the provider competence, preferably through face-to-face interactions; and hospital leadership support for ASP goals and for protected time for ASP activities is critical for success.

Conclusions

The physician-pharmacist team is essential for ASPs; most have pharmacists leading and performing day-to-day activities with physician support. Collaborative, persuasive approaches for ASP interventions were the norm. Stewards were careful not to criticize or judge inappropriate antibiotic prescribing. Further research should examine whether this persuasive approach undercuts provider appreciation of stewardship as a public health mandate.

Ushering in Antifungal Stewardship: Perspectives of the Hematology Multidisciplinary Team Navigating Competing Demands, Constraints, and Uncertainty

Background

The social, contextual, and behavioral determinants that influence care in patients at risk for invasive fungal diseases (IFD) are poorly understood. This knowledge gap is a barrier to the implementation of emerging antifungal stewardship (AFS) programs. We aimed to understand the barriers and enablers to AFS, opportunities for improvement, and perspectives of AFS for hematology patients at a major medical center in Australia.

Methods

Semistructured, face-to-face interviews were conducted with 35 clinicians from 6 specialties (hematology, infectious diseases, pharmacy, nursing, radiology, respiratory), followed by thematic analysis mapped to a behavioral change framework.

Results

Access to fungal diagnostics including bronchoscopy was identified as the key barrier to rational prescribing. Collective decision making was the norm, aided by an embedded stewardship model with on-demand access to infectious diseases expertise. Poor self-efficacy/knowledge among prescribers was actually an enabler of AFS, because clinicians willingly deferred to infectious diseases for advice. A growing outpatient population characterized by frequent care transitions was seen as an opportunity for AFS but neglected by an inpatient focused model, as was keeping pace with emerging fungal risks. Ad hoc surveillance, audit, and feedback practices frustrated population-level quality improvement for all actors. Antifungal stewardship was perceived as a specialized area that should be integrated within antimicrobial stewardship but aligned with the cultural expectations of hematologists.

Conclusions

Antifungal stewardship is multifaceted, with fungal diagnostics a critical gap and outpatients a neglected area. Formal surveillance, audit, and feedback mechanisms are essential for population-level quality improvement. Resourcing is the next challenge because complex immunocompromised patients require personalized attention and audit of clinical outcomes including IFD is difficult.

Perspective of Key Healthcare Professionals on Antimicrobial Resistance and Stewardship Programs: A Multicenter Cross-Sectional Study From Pakistan

Background: Antimicrobial resistance (AMR) is an increasing global threat, and hospital-based antimicrobial stewardship programs (ASPs) are one of the effective approaches to tackle AMR globally. This study was intended to determine the attitude of key healthcare professionals (HCPs), including physicians, nurses, and hospital pharmacists, towards AMR and hospital ASPs.

Methods: A cross-sectional study design was used to collect data from HCPs employed in public teaching hospitals of Punjab, Pakistan, from January 2019 to March 2019. A cluster-stratified sampling method was applied. Descriptive statistics, Mann Whitney and Kruskal Wallis tests were used for analysis.

Results: A response rate of 81.3% (881/1083) for the surveys was obtained. The majority of the physicians (247/410, 60.2%) perceived AMR to be a serious problem in Pakistani hospitals (p < 0.001). Most of the HCPs considered improving antimicrobial prescribing (580/881, 65.8%; p < 0.001) accompanied by the introduction of prospective audit with feedback (301/881, 75.8%; p < 0.001), formulary restriction (227/881, 57.2%; p = 0.004) and regular educational activities (300/881, 75.6%; p = 0.015) as effective ASP methods to implement hospital ASPs in Pakistan. A significant association was found between median AMR and ASP scores with age, years of experience, and types of HCPs (p < 0.05).

Conclusions: The attitude of most of the HCPs was observed to be positive towards hospital-based ASPs regardless of their poor awareness about ASPs. The important strategies, including prospective audit with feedback and regular educational sessions proposed by HCPs, will support the initiation and development of local ASPs for Pakistani hospitals.

Antimicrobial stewardship programs; a two-part narrative review of step-wise design and issues of controversy Part I: step-wise design of an antimicrobial stewardship program

Regardless of one's opinion of antimicrobial stewardship programs (ASPs), it is hardly possible to work in hospital care and not be exposed to the term or its practical effects. Despite the term being relatively new, the number of publications in the field is vast, including several excellent reviews of general and specific aspects. Work in antimicrobial stewardship is complex, and includes not only aspects of infectious disease and microbiology, but also of epidemiology, genetics, behavioural psychology, systems science, economics and ethics, to name a few. This review aims to take several of these aspects and the scientific evidence of antimicrobial stewardship studies and merge them into two questions: How should we design ASPs based on what we know today? And which are the most essential unanswered questions regarding antimicrobial stewardship on a broader scale? This narrative review is written in two separate parts aiming to provide answers to the two questions. This first part is written as a step-wise approach to designing a stewardship intervention based on the pillars of unmet need, feasibility, scientific evidence and necessary core elements. It is written mainly as a guide to someone new to the field. It is sorted into five distinct steps: (a) focusing on designing aims; (b) assessing performance and local barriers to rational antimicrobial use; (c) deciding on intervention technique; (d) practical, tailored design including core element inclusion; and (e) evaluation and sustainability. The second part, published separately, formulates ten critical questions on controversies in the field of antimicrobial stewardship. It is aimed at clinicians and researchers with stewardship experience and strives to promote discussion, not to provide answers.

Outcomes of an electronic medical record (EMR)-driven intensive care unit (ICU)-antimicrobial stewardship (AMS) ward round: Assessing the "Five Moments of Antimicrobial Prescribing"

OBJECTIVE

The primary objective of this study was to examine the impact of an electronic medical record (EMR)-driven intensive care unit (ICU) antimicrobial stewardship (AMS) service on clinician compliance with face-to-face AMS recommendations. AMS recommendations were defined by an internally developed "5 Moments of Antimicrobial Prescribing" metric: (1) escalation, (2) de-escalation, (3) discontinuation, (4) switch, and (5) optimization. The secondary objectives included measuring the impact of this service on (1) antibiotic appropriateness, and (2) use of high-priority target antimicrobials.

METHODS

A prospective review was undertaken of the implementation and compliance with a new ICU-AMS service that utilized EMR data coupled with face-to-face recommendations. Additional patient data were collected when an AMS recommendation was made. The impact of the ICU-AMS round on antimicrobial appropriateness was evaluated using point-prevalence survey data.

RESULTS

For the 202 patients, 412 recommendations were made in accordance with the "5 Moments" metric. The most common recommendation made by the ICU-AMS team was moment 3 (discontinuation), which comprised 173 of 412 recommendations (42.0%), with an acceptance rate of 83.8% (145 of 173). Data collected for point-prevalence surveys showed an increase in prescribing appropriateness from 21 of 45 (46.7%) preintervention (October 2016) to 30 of 39 (76.9%) during the study period (September 2017).

CONCLUSIONS

The integration of EMR with an ICU-AMS program allowed us to implement a new AMS service, which was associated with high clinician compliance with recommendations and improved antibiotic appropriateness. Our "5 Moments of Antimicrobial Prescribing" metric provides a framework for measuring AMS recommendation compliance.

Attitude of clinicians towards hospital-based antimicrobial stewardship programs: a multicenter cross-sectional study from Punjab, Pakistan

Background: Antimicrobial resistance (AMR) is a major threat to global health and antimicrobial stewardship programs (ASPs) are useful to limit the momentum of AMR. This study was intended to determine the attitudes of clinicians about AMR, ASP strategies, and their readiness to participate in ASPs. Methods: A cross-sectional survey was carried out among clinicians working in teaching hospitals of Punjab between August and November 2018. A multistage sampling method was used. Descriptive statistics and Kruskal-Wallis tests were employed for data analysis. Results: A response rate of 77.9% (670 ⁄ 859) was achieved. Most of the physicians (n = 302, 71.7%) compared to surgeons (n = 134, 70.9%) and anesthetists (n = 25, 41.7%) considered AMR as a serious health problem in Pakistani hospitals (p < 0.001). Clinicians were agreed that hospital audit and feedback (n = 434, 64.8%), restriction of certain antibiotics (n = 424, 63.3%), readily accessible microbiological data (n = 453, 67.6%), and regular educational sessions (n = 496, 74.0%) are imperative approaches to implement ASPs. Median ASP and AMR scores were significantly associated with age, experience, and types of clinicians (p < 0.05). Conclusions: Despite poor previous knowledge of ASPs, all clinicians showed a positive attitude towards hospital ASPs. Several approaches suggested by clinicians will be helpful to implement hospital ASPs in Pakistan.

Perspective of Pakistani Physicians towards Hospital Antimicrobial Stewardship Programs: A Multisite Exploratory Qualitative Study

Background: Antimicrobial resistance (AMR) is a global threat and the antimicrobial stewardship program (ASP) is a globally used tool to combat AMR. There is little information on the views among Pakistani physicians regarding AMR and the benefits of hospital antimicrobial stewardship implementation. This study was designed to explore the physicians’ views about ASP. Methods: Qualitative face-to-face and telephonic interviews were conducted by using purposive sampling method with 22 physicians working in seven tertiary care public hospitals of Punjab, Pakistan. All interviews were audio recorded and transcribed verbatim. Qualitative software was used, and a thematic analysis was conducted. Results: Three broad themes were identified: (1) the growing concern of antimicrobial resistance in Pakistan, (2) the role(s) of healthcare professionals in antibiotic prescribing, and (3) managing antibiotic resistance in hospitals. Inadequate resources, poor healthcare facilities, and insufficiently trained medical staff were the major hurdles in ASP implementation in Pakistan. Conclusions: Our study found a poor familiarity of hospital ASP among physicians working in public sector tertiary care teaching hospitals, and a number of distinct themes emerged during this study that could be helpful in establishing the concept of hospital ASP in Pakistan. Overall, physicians showed a positive attitude towards the enforcement of ASP in all healthcare settings, including teaching hospitals.

Threatened efficiency not autonomy: Prescriber perceptions of an established pediatric antimicrobial stewardship program

BACKGROUND

Implementing antimicrobial stewardship programs (ASPs) can be challenging due to prescriber resistance. Although barriers to implementing new ASPs have been identified, little is known about how prescribers perceive established programs. This information is critical to promoting the sustainability of ASPs.

OBJECTIVE

To identify how prescribers perceive an established pediatric inpatient ASP that primarily utilizes prior authorization.

METHODS

We conducted a cross-sectional survey administered from February through June 2017 in a large children's hospital. The survey contained closed- and open-ended questions. Descriptive statistics and thematic content analysis approaches were used to analyze responses.

RESULTS

Of 394 prescribers invited, 160 (41%) responded. Prescribers had an overall favorable impression of the ASP, believing that it improves the quality of care (92.4% agree) and takes their judgment seriously (73.8%). The most common criticism of the ASP was that it threatened efficiency (26.0% agreed). In addition, 68.7% of respondents reported occasionally engaging in workarounds. Analysis of 133 free-text responses revealed that prescribers perceived that interacting with the ASP involved too many phone calls, caused communication breakdowns with the dispensing pharmacy, and led to gaps between approval and dispensing of antibiotics. Reasons given for workarounds included not wanting to change therapy that appears to be working, consultant disagreement with ASP recommendations, and the desire to do everything possible for patients.

CONCLUSIONS

Prescribers had a generally favorable opinion of an established ASP but found aspects to be inefficient. They reported engaging in workarounds occasionally for social and emotional reasons. Established ASPs should elicit feedback from frontline prescribers to optimize program impact.

Specifying an implementation framework for Veterans Affairs antimicrobial stewardship programmes: using a factor analysis approach

Objectives

Inappropriate antibiotic use poses a serious threat to patient safety. Antimicrobial stewardship programmes (ASPs) may optimize antimicrobial use and improve patient outcomes, but their implementation remains an organizational challenge. Using the Promoting Action on Research Implementation in Health Services (PARiHS) framework, this study aimed to identify organizational factors that may facilitate ASP design, development and implementation.

Methods

Among 130 Veterans Affairs facilities that offered acute care, we classified organizational variables supporting antimicrobial stewardship activities into three PARiHS domains: evidence to encompass sources of knowledge; contexts to translate evidence into practice; and facilitation to enhance the implementation process. We conducted a series of exploratory factor analyses to identify conceptually linked factor scales. Cronbach's alphas were calculated. Variables with large uniqueness values were left as single factors.

Results

We identified 32 factors, including six constructs derived from factor analyses under the three PARiHS domains. In the evidence domain, four factors described guidelines and clinical pathways. The context domain was broken into three main categories: (i) receptive context (15 factors describing resources, affiliations/networks, formalized policies/practices, decision-making, receptiveness to change); (ii) team functioning (1 factor); and (iii) evaluation/feedback (5 factors). Within facilitation, two factors described facilitator roles and tasks and five captured skills and training.

Conclusions

We mapped survey data onto PARiHS domains to identify factors that may be adapted to facilitate ASP uptake. Our model encompasses mostly mutable factors whose relationships with performance outcomes may be explored to optimize antimicrobial use. Our framework also provides an analytical model for determining whether leveraging existing organizational processes can potentially optimize ASP performance.

Balancing the risks to individual and society: a systematic review and synthesis of qualitative research on antibiotic prescribing behaviour in hospitals

BACKGROUND

Antimicrobial resistance is a global health threat, partly driven by inappropriate antibiotic prescriptions for acute medical patients in hospitals.

AIM

To provide a systematic review of qualitative research on antibiotic prescribing decisions in hospitals worldwide, including broad-spectrum antibiotic use.

METHODS

A systematic search of qualitative research on antibiotic prescribing for adult hospital patients published between 2007 and 2017 was conducted. Drawing on the Health Belief Model, a framework synthesis was conducted to assess threat perceptions associated with antimicrobial resistance, and perceived benefits and barriers associated with antibiotic stewardship.

FINDINGS

The risk of antimicrobial resistance was generally perceived to be serious, but the abstract and long-term nature of its consequences led physicians to doubt personal susceptibility. While prescribers believed in the benefits of optimizing prescribing, the direct link between over-prescribing and antimicrobial resistance was questioned, and prescribers' behaviour change was frequently considered futile when fighting the complex problem of antimicrobial resistance. The salience of individual patient risks was a key barrier to more conservative prescribing. Physicians perceived broad-spectrum antibiotics to be effective and low risk; prescribing broad-spectrum antibiotics involved low cognitive demand and enabled physicians to manage patient expectations. Antibiotic prescribing decisions in low-income countries were shaped by a context of heightened uncertainty and risk due to poor microbiology and infection control services.

CONCLUSIONS

When tackling antimicrobial resistance, the tensions between immediate individual risks and long-term collective risks need to be taken into account. Efforts to reduce diagnostic uncertainty and to change risk perceptions will be critical in shifting practice.

A Qualitative Study of the Real-world Experiences of Infectious Diseases Fellows Regarding Antibiotic Stewardship

Background

Antibiotic-resistant bacterial infections are a major threat to public health, yet improper use of antibiotics remains high. Infectious Diseases (ID) fellows play a major role in antibiotic stewardship efforts, but there is little research on how they view stewardship activities. We performed a qualitative study to explore ID fellows’ experiences and perspectives regarding their antibiotic stewardship training and their role as future antibiotic stewards.

Methods

We conducted 17 in-depth interviews with ID fellows across the country. The interviews were transcribed verbatim by the study team, and we used grounded theory to generate themes from these interviews

Results

Fellows focused on concrete tasks of stewardship such as performing antibiotic approvals, didactic and case-based education, and interactions with other physicians and pharmacists. There was little focus on the broader public health relevance of antibiotic stewardship. Pharmacists, not ID physician leaders, were identified as fellows’ primary resource for antibiotic teaching. Several fellows suggested that stewardship programs should be led by pharmacists.

Conclusions

ID fellowship training is not successfully conveying the public health importance of antibiotic stewardship or the role of ID physicians as leaders of antibiotic stewardship programs. Fellows are more focused on concrete tasks related to stewardship. ID training programs and societies should consider developing robust curricula involving fellows in the operation of the stewardship program itself, not solely in antibiotic approvals, emphasizing aspects of the program such as complex problem solving that fellows find most compelling, and emphasizing the important role these programs serve in improving public health.

How do professional relationships influence surgical antibiotic prophylaxis decision making? A qualitative study

BACKGROUND

Surgical antibiotic prophylaxis (SAP) is a critical area to optimize to reduce the escalation of antimicrobial resistance. This article explores the ways by which interpersonal relationships influence SAP decision making.

METHODS

Twenty surgeons and anesthetists participated in in-depth semistructured interviews on SAP prescribing. Results were analyzed using the framework approach.

RESULTS

Analysis revealed 3 ways by which interpersonal relationships influence SAP: relationship dynamics between the surgeon and the anesthetist determine appropriateness of SAP, particularly operative risk ownership; perceived hierarchies within, and between, surgical and anesthetist specialties influence antibiotic prescribing decisions; and surgical distance from the antimicrobial stewardship team, which influences use of antimicrobial stewardship principles.

CONCLUSIONS

Interventions to optimize SAP are more likely to be effective in enacting sustained change if they consider the interpersonal and social contexts, including issues of familiarity and cohesiveness, hierarchical patterns, and sense of place within a team. Significant relational dynamics in SAP decision making are centered around risk; that is, personal/reputational risk to different professional groups and ownership of risk for individual patient outcomes. Risk must therefore be considered for sustainable SAP optimization interventions.

Experiences and perspectives of implementing antimicrobial stewardship in five French hospitals: a qualitative study

The aim of this study was to describe current antimicrobial stewardship programmes (ASPs) in France, both at policy level and at local implementation level, and to assess how ASP leaders (ASPL) worked and prioritised their activities. A qualitative study based on face-to-face semi-structured interviews with healthcare professionals responsible for ASPs across five French hospitals was conducted. Five infectious diseases specialists and one microbiologist were interviewed between April-June 2016. Stewards had dedicated time to perform ASP activities in two university-affiliated hospitals, whilst in the other hospitals (one university, one general and one semi-private), ASPLs had to balance these activities with clinical practice. Consequently, they had to adapt interventions according to their resources (IT or human). Responding to colleagues' consultation requests formed baseline work. Systematic and pro-active measures allowed for provision of unsolicited counselling, whilst direct counselling on wards required appropriate staffing. ASPLs aimed at increasing clinicians' ability to prescribe adequately and awareness of the unintended consequences of inappropriate use of antibiotics. Thus, persuasive, e.g. education, measures were preferred to coercive ones. ASPLs faced several challenges in implementing the ASP: overcoming physicians' or units' reluctance; and balancing the influence of medical hierarchy and professional boundaries. Beyond resources constraints, ASPLs' conceptions of their work, as well as contextual and cultural aspects, led them to adopt a persuasive and collaborative approach of counselling. This is the first qualitative study regarding ASPs in France exploring stewards' experiences and points of view.