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Ayorinde A, Ghosh I, Shaikh J, Adetunji V, Brown A, Jordan M, Gilham E, Todkill D, Ashiru-Oredope D. Improving healthcare professionals' interactions with patients to tackle antimicrobial resistance: a systematic review of interventions, barriers, and facilitators. Front Public Health 2024; 12:1359790. [PMID: 38841670 PMCID: PMC11150712 DOI: 10.3389/fpubh.2024.1359790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 04/30/2024] [Indexed: 06/07/2024] Open
Abstract
Introduction Antimicrobial resistance (AMR) is a major public health threat. With the growing emphasis on patient-centred care/ shared decision making, it is important for healthcare professionals' (HCPs) who prescribe, dispense, administer and/or monitor antimicrobials to be adequately equipped to facilitate appropriate antimicrobial use. We systematically identified existing interventions which aim to improve HCPs interaction with patients and examined barriers and facilitators of appropriate the use of such interventions and appropriate antimicrobial use among both HCPs and patientsantimicrobial use while using these interventions. Methods We searched MEDLINE, EMBASE, Web of Science, Google Scholar, and internet (via Google search engine). We included primary studies, published in English from 2010 to 2023 [PROSPERO (CRD42023395642)]. The protocol was preregistered with PROSPERO (CRD42023395642). We performed quality assessment using mixed methods appraisal tool. We applied narrative synthesis and used the COM-B (Capability, Opportunity, Motivation -Behaviour) as a theoretical framework for barriers and facilitators at HCP and patient levels. Results Of 9,172 citations retrieved from database searches, From 4,979 citations remained after removal of duplicates. We included 59 studies spanning over 13 countries. Interventions often involved multiple components beyond HCPs' interaction with patients. From 24 studies reporting barriers and facilitators, we identified issues relating to capability (such as, knowledge/understanding about AMR, diagnostic uncertainties, awareness of interventions and forgetfulness); opportunity (such as, time constraint and intervention accessibility) and motivation (such as, patient's desire for antibiotics and fear of litigation). Conclusion The findings of this review should be considered by intervention designers/adopters and policy makers to improve utilisation and effectiveness.
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Affiliation(s)
- Abimbola Ayorinde
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Iman Ghosh
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Junaid Shaikh
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Victoria Adetunji
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Anna Brown
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Mary Jordan
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Ellie Gilham
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Daniel Todkill
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Diane Ashiru-Oredope
- UK Health Security Agency, London, United Kingdom
- School of Pharmacy, University of Nottingham, Nottingham, United Kingdom
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Owens R, Bamford K, Pinion S, Garry E, Cranmer E, Pearce C, Wint HH, Gill S, Philips R, Khan A, Roy Bentley S, Roberts N, Keating B, Askaroff N, Morphew M, Orr C, Mouket T, Pope K, Powell N. Assessment of the appropriateness of antibiotic prescribing in an acute UK hospital using a national audit tool: a single centre retrospective survey. Eur J Hosp Pharm 2023:ejhpharm-2022-003569. [PMID: 37117009 DOI: 10.1136/ejhpharm-2022-003569] [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: 10/04/2022] [Accepted: 03/28/2023] [Indexed: 04/30/2023] Open
Abstract
INTRODUCTION Antibiotic use drives antibiotic resistance. The UK antimicrobial resistance (AMR) strategy aims to reduce antibiotic use. We aimed to quantify excess antibiotic use in a district general hospital in south-west England. METHODS Medical patients discharged in August 2020 who had received antibiotics were included. An audit tool of antibiotic prescribing appropriateness was used to collect relevant clinical information regarding each patient case. The appropriateness of antibiotic use was then determined by two infection specialists and excess days of therapy (DOTs) calculated. RESULTS 647 patients were discharged in August 2020. Of the 1658 antibiotic DOTs for the 184 patients reviewed, 403 (24%) were excess DOTs. The excess antibiotic DOTs were prescribed in 92 patients (50%); 112/403 (27.8%) excess DOTs originated at the initiation of antibiotic therapy (time point A); 184/403 (45.7%) of excess DOTs occurred at the antibiotic review pre-72 hours (time point B); and 107/403 (26.6%) of excess DOTs were due to protracted antibiotic courses (time point C). CONCLUSION 24% of antibiotic DOTs were deemed unnecessary. The greatest opportunity to reduce antibiotic use safely was the pre-72 hours antibiotic review, which may provide a target for reducing excess antimicrobial therapy in line with the national AMR strategy.
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Affiliation(s)
- Rhys Owens
- Emergency Department, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Kathy Bamford
- Medical Microbiology, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Sophie Pinion
- Anaesthetics, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Emma Garry
- Department of Obstetrics and Gynaecology, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Emily Cranmer
- Eldercare, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Catharine Pearce
- Respiratory department, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Htet Htet Wint
- Neurology department, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Simon Gill
- Respiratory department, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Ryan Philips
- Acute Medicine, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Adnan Khan
- Eldercare, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Selina Roy Bentley
- Enhanced Perioperative Care Unit, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Neil Roberts
- University Hositals Plymouth NHS Trust, Plymouth, UK
| | | | - Natasha Askaroff
- Oncology Department, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Megan Morphew
- Oncology, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Charles Orr
- Emergency Department, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Tarek Mouket
- Acute Medicine, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Katherine Pope
- Acute Medicine, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Neil Powell
- Pharmacy Department, Royal Cornwall Hospital NHS Trust, Cornwall, UK
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Antibiotic review kit for hospitals (ARK-Hospital): a stepped-wedge cluster-randomised controlled trial. THE LANCET. INFECTIOUS DISEASES 2023; 23:207-221. [PMID: 36206793 DOI: 10.1016/s1473-3099(22)00508-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 07/04/2022] [Accepted: 07/15/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Strategies to reduce antibiotic overuse in hospitals depend on prescribers taking decisions to stop unnecessary antibiotic use. There is scarce evidence for how to support these decisions. We evaluated a multifaceted behaviour change intervention (ie, the antibiotic review kit) designed to reduce antibiotic use among adult acute general medical inpatients by increasing appropriate decisions to stop antibiotics at clinical review. METHODS We performed a stepped-wedge, cluster (hospital)-randomised controlled trial using computer-generated sequence randomisation of eligible hospitals in seven calendar-time blocks in the UK. Hospitals were eligible for inclusion if they admitted adult non-elective general or medical inpatients, had a local representative to champion the intervention, and could provide the required study data. Hospital clusters were randomised to an implementation date occurring at 1-2 week intervals, and the date was concealed until 12 weeks before implementation, when local preparations were designed to start. The intervention effect was assessed using data from pseudonymised routine electronic health records, ward-level antibiotic dispensing, Clostridioides difficile tests, prescription audits, and an implementation process evaluation. Co-primary outcomes were monthly antibiotic defined daily doses per adult acute general medical admission (hospital-level, superiority) and all-cause mortality within 30 days of admission (patient level, non-inferiority margin of 5%). Outcomes were assessed in the modified intention-to-treat population (ie, excluding sites that withdrew before implementation). Intervention effects were assessed by use of interrupted time series analyses within each site, estimating overall effects through random-effects meta-analysis, with heterogeneity across prespecified potential modifiers assessed by use of meta-regression. This trial is completed and is registered with ISRCTN, ISRCTN12674243. FINDINGS 58 hospital organisations expressed an interest in participating. Three pilot sites implemented the intervention between Sept 25 and Nov 20, 2017. 43 further sites were randomised to implement the intervention between Feb 12, 2018, and July 1, 2019, and seven sites withdrew before implementation. 39 sites were followed up for at least 14 months. Adjusted estimates showed reductions in total antibiotic defined daily doses per acute general medical admission (-4·8% per year, 95% CI -9·1 to -0·2) following the intervention. Among 7 160 421 acute general medical admissions, the ARK intervention was associated with an immediate change of -2·7% (95% CI -5·7 to 0·3) and sustained change of 3·0% (-0·1 to 6·2) in adjusted 30-day mortality. INTERPRETATION The antibiotic review kit intervention resulted in sustained reductions in antibiotic use among adult acute general medical inpatients. The weak, inconsistent intervention effects on mortality are probably explained by the onset of the COVID-19 pandemic. Hospitals should use the antibiotic review kit to reduce antibiotic overuse. FUNDING UK National Institute for Health and Care Research.
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Weir CJ, Adamestam I, Sharp R, Ennis H, Heed A, Williams R, Cresswell K, Dogar O, Pontefract S, Coleman J, Lilford R, Watson N, Slee A, Chuter A, Beggs J, Slight S, Mason J, Yardley L, Sheikh A. A complex ePrescribing-based Anti-Microbial Stewardship (ePAMS+) intervention for hospitals combining technological and behavioural components: protocol for a feasibility trial. Pilot Feasibility Stud 2023; 9:18. [PMID: 36709308 PMCID: PMC9883604 DOI: 10.1186/s40814-022-01230-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 12/16/2022] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Antimicrobial resistance is a leading global public health threat, with inappropriate use of antimicrobials in healthcare contributing to its development. Given this urgent need, we developed a complex ePrescribing-based Anti-Microbial Stewardship intervention (ePAMS+). METHODS ePAMS+ includes educational and organisational behavioural elements, plus guideline-based clinical decision support to aid optimal antimicrobial use in hospital inpatients. ePAMS+ particularly focuses on prompt initiation of antimicrobials, followed by early review once test results are available to facilitate informed decision-making on stopping or switching where appropriate. A mixed-methods feasibility trial of ePAMS+ will take place in two NHS acute hospital care organisations. Qualitative staff interviews and observation of practice will respectively gather staff views on the technical component of ePAMS+ and information on their use of ePAMS+ in routine work. Focus groups will elicit staff and patient views on ePAMS+; one-to-one interviews will discuss antimicrobial stewardship with staff and will record patient experiences of receiving antibiotics and their thoughts on inappropriate prescribing. Qualitative data will be analysed thematically. Fidelity Index development will enable enactment of ePAMS+ to be measured objectively in a subsequent trial assessing the effectiveness of ePAMS+. Quantitative data collection will determine the feasibility of extracting data and deriving key summaries of antimicrobial prescribing; we will quantify variability in the primary outcome, number of antibiotic defined daily doses, to inform the future larger-scale trial design. DISCUSSION This trial is essential to determine the feasibility of implementing the ePAMS+ intervention and measuring relevant outcomes, prior to evaluating its clinical and cost-effectiveness in a full scale hybrid cluster-randomised stepped-wedge clinical trial. Findings will be shared with study sites and with qualitative research participants and will be published in peer-reviewed journals and presented at academic conferences. TRIAL REGISTRATION The qualitative and Fidelity Index research were approved by the Health and Research Authority and the North of Scotland Research Ethics Service (ref: 19/NS/0174). The feasibility trial and quantitative analysis (protocol v1.0, 15 December 2021) were approved by the London South East Research Ethics Committee (ref: 22/LO/0204) and registered with ISRCTN ( ISRCTN 13429325 ) on 24 March 2022.
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Affiliation(s)
- Christopher J Weir
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK.
| | - Imad Adamestam
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Rona Sharp
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Holly Ennis
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Andrew Heed
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Robin Williams
- Institute for the Study of Science, Technology and Innovation, University of Edinburgh, Edinburgh, UK
| | | | - Omara Dogar
- Usher Institute, University of Edinburgh, Edinburgh, UK
- Department of Health Sciences, University of York, York, UK
| | - Sarah Pontefract
- Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Jamie Coleman
- Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
| | | | - Neil Watson
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
- NHS Covid Vaccine North East and North Cumbria, Carlisle, UK
| | | | - Antony Chuter
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Jillian Beggs
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Sarah Slight
- School of Pharmacy, Newcastle University, Newcastle, UK
| | - James Mason
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Lucy Yardley
- School of Psychological Science, University of Bristol, Bristol, UK
- School of Psychology, University of Southampton, Southampton, UK
| | - Aziz Sheikh
- Usher Institute, University of Edinburgh, Edinburgh, UK
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5
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Calderon M, Gysin G, Gujjar A, McMaster A, King L, Comandé D, Hunter E, Payne B. Bacterial co-infection and antibiotic stewardship in patients with COVID-19: a systematic review and meta-analysis. BMC Infect Dis 2023; 23:14. [PMID: 36624396 PMCID: PMC9828368 DOI: 10.1186/s12879-022-07942-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 12/12/2022] [Indexed: 01/11/2023] Open
Abstract
INTRODUCTION Understanding the proportion of patients with COVID-19 who have respiratory bacterial co-infections and the responsible pathogens is important for managing COVID-19 effectively while ensuring responsible antibiotic use. OBJECTIVE To estimate the frequency of bacterial co-infection in COVID-19 hospitalized patients and of antibiotic prescribing during the early pandemic period and to appraise the use of antibiotic stewardship criteria. METHODS Systematic review and meta-analysis was performed using major databases up to May 5, 2021. We included studies that reported proportion/prevalence of bacterial co-infection in hospitalized COVID-19 patients and use of antibiotics. Where available, data on duration and type of antibiotics, adverse events, and any information about antibiotic stewardship policies were also collected. RESULTS We retrieved 6,798 studies and included 85 studies with data from more than 30,000 patients. The overall prevalence of bacterial co-infection was 11% (95% CI 8% to 16%; 70 studies). When only confirmed bacterial co-infections were included the prevalence was 4% (95% CI 3% to 6%; 20 studies). Overall antibiotic use was 60% (95% CI 52% to 68%; 52 studies). Empirical antibiotic use rate was 62% (95% CI 55% to 69%; 11 studies). Few studies described criteria for stopping antibiotics. CONCLUSION There is currently insufficient evidence to support widespread empirical use of antibiotics in most hospitalised patients with COVID-19, as the overall proportion of bacterial co-infection is low. Furthermore, as the use of antibiotics during the study period appears to have been largely empirical, clinical guidelines to promote and support more targeted administration of antibiotics in patients admitted to hospital with COVID-19 are required.
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Affiliation(s)
- Maria Calderon
- grid.419334.80000 0004 0641 3236Department of Infection and Tropical Medicine, Newcastle-Upon-Tyne Hospitals NHS Foundation Trust, Royal Victoria Infirmary, Queen Victoria Rd., Newcastle-Upon-Tyne, NE1 4LP UK
| | - Grace Gysin
- grid.1006.70000 0001 0462 7212Translational and Clinical Research Institute, Newcastle University, Newcastle-Upon-Tyne, NE1 7RU UK ,grid.1006.70000 0001 0462 7212School of Medicine, Newcastle University, Newcastle-Upon-Tyne, UK
| | - Akash Gujjar
- grid.1006.70000 0001 0462 7212School of Medicine, Newcastle University, Newcastle-Upon-Tyne, UK
| | - Ashleigh McMaster
- grid.419334.80000 0004 0641 3236Department of Infection and Tropical Medicine, Newcastle-Upon-Tyne Hospitals NHS Foundation Trust, Royal Victoria Infirmary, Queen Victoria Rd., Newcastle-Upon-Tyne, NE1 4LP UK
| | - Lisa King
- grid.1006.70000 0001 0462 7212School of Medicine, Newcastle University, Newcastle-Upon-Tyne, UK
| | - Daniel Comandé
- grid.414661.00000 0004 0439 4692Instituto de Efectividad Clinica y Sanitaria, Emilio Ravignani 2024 (C1414CPV), Buenos Aires, Argentina
| | - Ewan Hunter
- grid.419334.80000 0004 0641 3236Department of Infection and Tropical Medicine, Newcastle-Upon-Tyne Hospitals NHS Foundation Trust, Royal Victoria Infirmary, Queen Victoria Rd., Newcastle-Upon-Tyne, NE1 4LP UK
| | - Brendan Payne
- grid.419334.80000 0004 0641 3236Department of Infection and Tropical Medicine, Newcastle-Upon-Tyne Hospitals NHS Foundation Trust, Royal Victoria Infirmary, Queen Victoria Rd., Newcastle-Upon-Tyne, NE1 4LP UK ,grid.1006.70000 0001 0462 7212Translational and Clinical Research Institute, Newcastle University, Newcastle-Upon-Tyne, NE1 7RU UK
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Roy-Bentley S, Bethune R, Powell N. Implementation of the Antimicrobial Review Kit (ARK) to optimise antimicrobial prescribing at the Royal Cornwall Hospital: a behavioural change odyssey. Clin Med (Lond) 2022; 22:455-460. [PMID: 38589067 PMCID: PMC9595014 DOI: 10.7861/clinmed.2021-0757] [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] [Indexed: 12/15/2022]
Abstract
Antibiotic use drives antimicrobial resistance (AMR). The Antimicrobial Review Kit (ARK) study is a complex intervention based on national antibiotic stewardship guidance. We describe the implementation of ARK at a 760-bed teaching hospital that uses electronic prescribing. An online education module was disseminated to healthcare workers, and the ARK decision tool was incorporated into the medical clerking pro forma. From July 2018, junior doctors audited the frequency, the outcomes of pre-72-hour antibiotic reviews and the use of the ARK tool. The data were used to formulate specialty-level feedback and bench marking. First-phase data were plotted on statistical process control (SPC) charts to distinguish between common and special cause variation. There was significant improvement in antibiotic review rates (81% to 93%) and stop rates (10% to 15%). The stop rate reached 25% in the most recent data. Given the promising trends, it may be possible to achieve the target stop rate of 30%.
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Affiliation(s)
| | | | - Neil Powell
- Royal Cornwall Hospitals NHS Trust, Treliske, UK
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7
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Budgell EP, Davies TJ, Donker T, Hopkins S, Wyllie DH, Peto TEA, Gill MJ, Llewelyn MJ, Walker AS. Impact of hospital antibiotic use on patient-level risk of death among 36,124,372 acute and medical admissions in England. J Infect 2021; 84:311-320. [PMID: 34963640 DOI: 10.1016/j.jinf.2021.12.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 12/03/2021] [Accepted: 12/17/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Initiatives to curb hospital antibiotic use might be associated with harm from under-treatment. We examined the extent to which variation in hospital antibiotic prescribing is associated with mortality risk in acute/general medicine inpatients. METHODS This ecological analysis examined Hospital Episode Statistics from 36,124,372 acute/general medicine admissions (≥16y) to 135 acute hospitals in England, 01/April/2010-31/March/2017. Random-effects meta-regression was used to investigate whether heterogeneity in adjusted 30-day mortality was associated with hospital-level antibiotic use, measured in defined-daily-doses (DDD)/1,000 bed-days. Models also considered DDDs/1,000 admissions and DDDs for narrow-spectrum/broad-spectrum antibiotics, parenteral/oral, and local interpretations of World Health Organization Access, Watch, and Reserve antibiotics. RESULTS Hospital-level antibiotic DDDs/1,000 bed-days varied 15-fold with comparable variation in broad-spectrum, parenteral, and Reserve antibiotic use. After extensive adjusting for hospital case-mix, the probability of 30-day mortality changed -0.010% (95% CI: -0.064,+0.044) for each increase of 500 hospital-level antibiotic DDDs/1,000 bed-days. Analyses of other metrics of antibiotic use showed no consistent association with mortality risk. CONCLUSIONS We found no evidence that wide variation in hospital antibiotic use is associated with adjusted mortality risk in acute/general medicine inpatients. Using low-prescribing hospitals as benchmarks could help drive safe and substantial reductions in antibiotic consumption of up-to one-third in this population.
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Affiliation(s)
- Eric P Budgell
- Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Timothy J Davies
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Tjibbe Donker
- Institute for Infection Prevention and Hospital Epidemiology, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Susan Hopkins
- National Infection Service, Public Health England, UK
| | | | - Tim E A Peto
- Nuffield Department of Medicine, University of Oxford, Oxford, UK; NIHR Biomedical Research Centre, Oxford, UK; National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Oxford, UK
| | - Martin J Gill
- Clinical Microbiology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Martin J Llewelyn
- Global Health and Infectious Diseases, Brighton and Sussex Medical School, University of Sussex, Brighton, UK; Department of Microbiology and Infection, Royal Sussex County Hospital, Brighton, UK
| | - A Sarah Walker
- Nuffield Department of Medicine, University of Oxford, Oxford, UK; NIHR Biomedical Research Centre, Oxford, UK; National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Oxford, UK
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Mowbray F, Sivyer K, Santillo M, Jones N, Peto TEA, Walker AS, Llewelyn MJ, Yardley L. Patient engagement with antibiotic messaging in secondary care: a qualitative feasibility study of the ‘review and revise’ experience. Pilot Feasibility Stud 2020; 6:43. [PMID: 32280483 PMCID: PMC7126355 DOI: 10.1186/s40814-020-00590-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 03/24/2020] [Indexed: 01/22/2023] Open
Abstract
Abstract
Background
We aimed to investigate and optimise the acceptability and usefulness of a patient leaflet about antibiotic prescribing decisions made during hospitalisation, and to explore individual patient experiences and preferences regarding the process of antibiotic prescription ‘review and revise’ which is a key strategy to minimise antibiotic overuse in hospitals.
Methods
In this qualitative study, run within the feasibility study of a large, cluster-randomised stepped wedge trial of 36 hospital organisations, a series of semi-structured, think-aloud telephone interviews were conducted and data were analysed using thematic analysis. Fifteen adult patients who had experienced a recent acute medical hospital admission during which they had been prescribed antimicrobials and offered a patient leaflet about antibiotic prescribing were recruited to the study.
Results
Participants reacted positively to the leaflet, reporting that it was both an accessible and important source of information which struck the appropriate balance between informing and reassuring. Participants all valued open communication with clinicians, and were keen to be involved in antibiotic prescribing decisions, with individuals reporting positive experiences regarding antibiotic prescription changes or stopping. Many participants had prior experience or knowledge of antibiotics and resistance, and generally welcomed efforts to reduce antibiotic usage. Overall, there was a feeling that healthcare professionals (HCPs) are trusted experts providing the most appropriate treatment for individual patient conditions.
Conclusions
This study offers novel insights into how patients within secondary care are likely to respond to messages advocating a reduction in the use of antibiotics through the ‘review and revise’ approach. Due to the level of trust that patients place in their care provider, encouraging HCPs within secondary care to engage patients with greater communication and information provision could provide great advantages in the drive to reduce antibiotic use. It may also be beneficial for HCPs to view patient experiences as cumulative events that have the potential to impact future behaviour around antibiotic use. Finally, pre-testing messages about antibiotic prescribing and resistance is vital to dispelling any misconceptions either around effectiveness of treatment for patients, or perceptions of how messages may be received.
Trial registration
Current Controlled Trials ISRCTN12674243 (10 April 2017),
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Affiliation(s)
- C Lynch
- Healthcare Infection Society, Montagu House, Wakefield Street, London, WC1N, UK.
| | - N Mahida
- Healthcare Infection Society, Montagu House, Wakefield Street, London, WC1N, UK
| | - J Gray
- Healthcare Infection Society, Montagu House, Wakefield Street, London, WC1N, UK
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10
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Lynch C, Mahida N, Oppenheim B, Gray J. Looking back on 2019 and commemorating 40 years of HIS and JHI. J Hosp Infect 2020; 104:1-3. [DOI: 10.1016/j.jhin.2019.11.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 11/28/2019] [Indexed: 10/25/2022]
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Walker AS, Budgell E, Laskawiec-Szkonter M, Sivyer K, Wordsworth S, Quaddy J, Santillo M, Krusche A, Roope LSJ, Bright N, Mowbray F, Jones N, Hand K, Rahman N, Dobson M, Hedley E, Crook D, Sharland M, Roseveare C, Hobbs FDR, Butler C, Vaughan L, Hopkins S, Yardley L, Peto TEA, Llewelyn MJ. Antibiotic Review Kit for Hospitals (ARK-Hospital): study protocol for a stepped-wedge cluster-randomised controlled trial. Trials 2019; 20:421. [PMID: 31296255 PMCID: PMC6625068 DOI: 10.1186/s13063-019-3497-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 06/05/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND To ensure patients continue to get early access to antibiotics at admission, while also safely reducing antibiotic use in hospitals, one needs to target the continued need for antibiotics as more diagnostic information becomes available. UK Department of Health guidance promotes an initiative called 'Start Smart then Focus': early effective antibiotics followed by active 'review and revision' 24-72 h later. However in 2017, < 10% of antibiotic prescriptions were discontinued at review, despite studies suggesting that 20-30% of prescriptions could be stopped safely. METHODS/DESIGN Antibiotic Review Kit for Hospitals (ARK-Hospital) is a complex 'review and revise' behavioural intervention targeting healthcare professionals involved in antibiotic prescribing or administration in inpatients admitted to acute/general medicine (the largest consumers of non-prophylactic antibiotics in hospitals). The primary study objective is to evaluate whether ARK-Hospital can safely reduce the total antibiotic burden in acute/general medical inpatients by at least 15%. The primary hypotheses are therefore that the introduction of the behavioural intervention will be non-inferior in terms of 30-day mortality post-admission (relative margin 5%) for an acute/general medical inpatient, and superior in terms of defined daily doses of antibiotics per acute/general medical admission (co-primary outcomes). The unit of observation is a hospital organisation, a single hospital or group of hospitals organised with one executive board and governance framework (National Health Service trusts in England; health boards in Northern Ireland, Wales and Scotland). The study comprises a feasibility study in one organisation (phase I), an internal pilot trial in three organisations (phase II) and a cluster (organisation)-randomised stepped-wedge trial (phase III) targeting a minimum of 36 organisations in total. Randomisation will occur over 18 months from November 2017 with a further 12 months follow-up to assess sustainability. The behavioural intervention will be delivered to healthcare professionals involved in antibiotic prescribing or administration in adult inpatients admitted to acute/general medicine. Outcomes will be assessed in adult inpatients admitted to acute/general medicine, collected through routine electronic health records in all patients. DISCUSSION ARK-Hospital aims to provide a feasible, sustainable and generalisable mechanism for increasing antibiotic stopping in patients who no longer need to receive them at 'review and revise'. TRIAL REGISTRATION ISRCTN Current Controlled Trials, ISRCTN12674243 . Registered on 10 April 2017.
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Affiliation(s)
- Ann Sarah Walker
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Eric Budgell
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Magda Laskawiec-Szkonter
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Katy Sivyer
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
| | - Sarah Wordsworth
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Jack Quaddy
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Marta Santillo
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
| | - Adele Krusche
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
| | - Laurence S. J. Roope
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Nicole Bright
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Fiona Mowbray
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
| | - Nicola Jones
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Kieran Hand
- University of Southampton, Southampton, UK
- University Hospital Southampton NHS Trust, Southampton, UK
| | - Najib Rahman
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Melissa Dobson
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Emma Hedley
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Derrick Crook
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | | | - F. D. Richard Hobbs
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Chris Butler
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Susan Hopkins
- Royal Free London NHS Foundation Trust, London, UK
- National Infection Service, Public Health England, London, UK
| | - Lucy Yardley
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
- School of Psychological Science, University of Bristol, Clifton, UK
| | - Timothy E. A. Peto
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - on behalf of the ARK trial team
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- University of Southampton, Southampton, UK
- University Hospital Southampton NHS Trust, Southampton, UK
- St George’s, University of London, London, UK
- Southern Health NHS Foundation Trust, Southampton, UK
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- The Nuffield Trust, London, UK
- Royal Free London NHS Foundation Trust, London, UK
- School of Psychological Science, University of Bristol, Clifton, UK
- National Infection Service, Public Health England, London, UK
- Brighton and Sussex Medical School, Brighton, UK
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