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Surendran S, Nampoothiri V, Dhar P, Holmes A, Singh S, Charani E. Rationalizing irrational prescribing-infection-related attitudes and practices across paediatric surgery specialties in a hospital in South India. JAC Antimicrob Resist 2024; 6:dlae105. [PMID: 39005590 PMCID: PMC11245696 DOI: 10.1093/jacamr/dlae105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Accepted: 06/18/2024] [Indexed: 07/16/2024] Open
Abstract
Background and objectives Antibiotic use in paediatric surgical specialties is understudied. We investigated the antibiotic prescribing practices of paediatric general and cardiovascular surgical teams in a tertiary hospital in South India. Methods Mixed-methods study including observations from ward rounds, semi-structured interviews, and review of antibiotic prescribing. Field notes from observations and interview transcripts were coded using NVivo and thematically analysed. Data collection and analysis were iterative and continued until thematic saturation. Quantitative data were analysed using descriptive statistics. Results Data included 62 h of observation, 24 interviews, one case study and 200 patient chart reviews (100/specialty). Senior surgeons make key decisions, referring to their own experience when prescribing antibiotics. Being outcome-driven, the doctors often prescribe antibiotics at the earliest indication of infection with a reluctance to de-escalate, even when an infection is not diagnosed. This practice is more acute among surgeons who consider themselves responsible for their patients' health and attribute the consistently low surgical site infection rates to this practice.In general surgery, 83.3% (80/96; 4 lost to follow-up) of patients were prescribed antibiotics for the duration of their stay with oral antibiotics prescribed at discharge. The surgeons use antibiotics prophylactically for patients who may be vulnerable to infection. The antimicrobial stewardship team was considered to have limited influence in the decision-making process. Conclusions Outcome-driven decision-making in surgery leads to overprescription of antibiotics and prolonged surgical prophylaxis. The rationale for suboptimal practices is complicated by the surgeons' beliefs about the contextual determinants of health in India.
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Affiliation(s)
- Surya Surendran
- Department of Infection Control and Epidemiology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham University, Kochi, Kerala, India
- Health System and Equity, The George Institute for Global Health, New Delhi, India
| | - Vrinda Nampoothiri
- Department of Infection Control and Epidemiology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham University, Kochi, Kerala, India
| | - Puneet Dhar
- Surgical Gastroenterology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Faridabad, India
| | - Alison Holmes
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
| | - Sanjeev Singh
- Department of Medical Admin, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Faridabad, India
| | - Esmita Charani
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
- Division of Infectious Diseases & HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
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Jamaluddin NAH, Periyasamy P, Lau CL, Ponnampalavanar S, Lai PSM, Loong LS, Tg Abu Bakar Sidik TMI, Ramli R, Tan TL, Kori N, Yin MK, Azman NJ, James R, Thursky K, Naina Mohamed I. Assessment of antimicrobial prescribing patterns, guidelines compliance, and appropriateness of antimicrobial prescribing in surgical-practice units: point prevalence survey in Malaysian teaching hospitals. Front Pharmacol 2024; 15:1381843. [PMID: 38720771 PMCID: PMC11076853 DOI: 10.3389/fphar.2024.1381843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Accepted: 03/28/2024] [Indexed: 05/12/2024] Open
Abstract
Objectives: This study sought to investigate the quality of antimicrobial prescribing among adult surgical inpatients besides exploring the determinants of non-compliance and inappropriate prescribing to inform stewardship activities. Methods: A cross-sectional point prevalence study employing Hospital National Antimicrobial Prescribing Survey (Hospital NAPS) was conducted in April 2019 at two teaching hospitals in Malaysia. Results: Among 566 surgical inpatients, 44.2% were receiving at least one antimicrobial, for a total of 339 prescriptions. Antimicrobials belonging to the World Health Organization's Watch group were observed in 57.8% of cases. Both hospitals exhibited similar types of antimicrobial treatments prescribed and administration routes. A significant difference in antimicrobial choice was observed between hospitals (p < 0.001). Hospital with electronic prescribing demonstrated better documentation practice (p < 0.001). Guidelines compliance, 32.8% (p = 0.952) and appropriateness, 55.2% (p = 0.561) did not significantly differ. The major contributors of inappropriateness were incorrect duration, (15%) and unnecessary broad-spectrum coverage, (15.6%). Non-compliance and inappropriate prescribing were found to be 2 to 4 times significantly higher with antimicrobial prophylaxis prescription compared to empirical therapy. Conclusion: Antimicrobial stewardship efforts to improve appropriate surgical prescribing are essential. These initiatives should prioritize surgical prophylaxis prescribing, focusing on reducing unnecessarily prolonged use and broad-spectrum antimicrobials, raising awareness among prescribers and promoting proper documentation.
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Affiliation(s)
- Nurul Adilla Hayat Jamaluddin
- Pharmacoepidemiology and Drug Safety Unit, Department of Pharmacology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
- Department of Hospital and Clinical Pharmacy, Faculty of Pharmacy, University of Cyberjaya, Cyberjaya, Selangor, Malaysia
| | - Petrick Periyasamy
- Medical Department, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Chee Lan Lau
- Pharmacoepidemiology and Drug Safety Unit, Department of Pharmacology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
- Pharmacy Department, Hospital Canselor Tuanku Muhriz, Kuala Lumpur, Malaysia
| | | | - Pauline Siew Mei Lai
- Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
- School of Medical and Life Sciences, Sunway University, Petaling Jaya, Selangor, Malaysia
| | - Ly Sia Loong
- Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Tg Mohd Ikhwan Tg Abu Bakar Sidik
- Pharmacoepidemiology and Drug Safety Unit, Department of Pharmacology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Ramliza Ramli
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Toh Leong Tan
- Emergency Department, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Najma Kori
- Medical Department, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Mei Kuen Yin
- Pharmacy Department, Hospital Canselor Tuanku Muhriz, Kuala Lumpur, Malaysia
| | - Nur Jannah Azman
- Pharmacy Department, Hospital Canselor Tuanku Muhriz, Kuala Lumpur, Malaysia
| | - Rodney James
- The Royal Melbourne Hospital, Melbourne, Australia
- National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, Melbourne, Australia
| | - Karin Thursky
- The Royal Melbourne Hospital, Melbourne, Australia
- National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, Melbourne, Australia
| | - Isa Naina Mohamed
- Pharmacoepidemiology and Drug Safety Unit, Department of Pharmacology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
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3
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Kourbeti I, Kamiliou A, Samarkos M. Antibiotic Stewardship in Surgical Departments. Antibiotics (Basel) 2024; 13:329. [PMID: 38667005 PMCID: PMC11047567 DOI: 10.3390/antibiotics13040329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 03/31/2024] [Accepted: 03/31/2024] [Indexed: 04/29/2024] Open
Abstract
Antimicrobial resistance (AMR) has emerged as one of the leading public health threats of the 21st century. New evidence underscores its significance in patients' morbidity and mortality, length of stay, as well as healthcare costs. Globally, the factors that contribute to antimicrobial resistance include social and economic determinants, healthcare governance, and environmental interactions with impact on humans, plants, and animals. Antimicrobial stewardship (AS) programs have historically overlooked surgical teams as they considered them more difficult to engage. This review aims to summarize the evolution and significance of AS in surgical wards, including the surgical intensive care unit (SICU) and the role of diagnostic stewardship (DS). The contribution of AS team members is presented. The new diagnostic modalities and the new technologies including artificial intelligence (AI) are also reviewed.
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Affiliation(s)
- Irene Kourbeti
- Department of Internal Medicine, School of Medicine, National and Kapodistrian, University of Athens, 11527 Athens, Greece; (A.K.); (M.S.)
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Sørensen TM, Scahill K, Ruperez JE, Olejnik M, Swinbourne F, Verwilghen DR, Nolff MC, Baines S, Marques C, Vilen A, Duarte EL, Dias M, Dewulf S, Wichtowska A, Valencia AC, Pelligand L, Broens EM, Toutain PL, Alishani M, Brennan ML, Weese JS, Jessen LR, Allerton F. Antimicrobial prophylaxis in companion animal surgery: A scoping review for European Network for Optimization of Antimicrobial Therapy (ENOVAT) guidelines. Vet J 2024; 304:106101. [PMID: 38490359 DOI: 10.1016/j.tvjl.2024.106101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 03/09/2024] [Accepted: 03/10/2024] [Indexed: 03/17/2024]
Abstract
Surgical antimicrobial prophylaxis (SAP) is widely used to reduce the risk of surgical site infections (SSI), but there is uncertainty as to what the proportion of SSI reduction is. Therefore, it is difficult for surgeons to properly weigh the costs, risks and benefits for individual patients when deciding on the use of SAP, making it challenging to promote antimicrobial stewardship in primary practice settings. The objective of this study was to map the veterinary evidence focused on assessing the effect of SAP on SSI development and in order to identify surgical procedures with some research evidence and possible knowledge gaps. In October 2021 and December 2022, Scopus, CAB Abstracts, Web of Science Core Collection, Embase and MEDLINE were systematically searched. Double blinded screening of records was performed to identify studies in companion animals that reported on the use of SAP and SSI rates. Comparative data were available from 34 out of 39123 records screened including: eight randomised controlled trials (RCT), 23 cohort studies (seven prospective and 16 retrospective) and three retrospective case series representing 12476 dogs and cats in total. Extracted data described peri- or post-operative SAP in nine, and 25 studies, respectively. In the eight RCTs evaluating SAP in companion animals, surgical procedure coverage was skewed towards orthopaedic stifle surgeries in referral settings and there was large variation in SAP protocols, SSI definitions and follow-up periods. More standardized data collection and agreement of SSI definitions is needed to build stronger evidence for optimized patient care.
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Affiliation(s)
- T M Sørensen
- Department of Veterinary Clinical Sciences, University of Copenhagen, Dyrlaegevej 16, Frederiksberg C 1870, Denmark; ESCMID Study Group for Veterinary Microbiology (ESGVM), Basel, Switzerland.
| | - K Scahill
- College of Medicine and Veterinary Medicine, University of Edinburgh, 49 Little France Crescent, Edinburgh EH16 4SB, United Kingdom; Evidensia Södra Djursjukhuset Kungens Kurva, Månskärarvägen 13, Kungens Kurva 14175, Sweden; ESCMID Study Group for Veterinary Microbiology (ESGVM), Basel, Switzerland
| | - J Espinel Ruperez
- College of Veterinary Medicine, Murdoch University, Murdoch, Perth, WA 6150, Australia
| | - M Olejnik
- Department of Fundamental and Preclinical Sciences, Nicolaus Copernicus University, Jurija Gagarina 11, Toruń 87-100, Poland
| | - F Swinbourne
- Lumbry Park Veterinary Specialists, Selborne Rd, Alton GU34 3HL, United Kingdom
| | - D R Verwilghen
- Sydney School of Veterinary Science, University of Sydney, Regimental Dr, Camperdown, NSW 2050, Australia
| | - M C Nolff
- Clinic for Small Animal Surgery, Vetsuisse Faculty, University Zürich, Winterthurerstrasse 260, TFA 01.51, Zürich 8057, Switzerland
| | - S Baines
- Willows Veterinary Centre & Referral Service, Solihull B90 4NH, United Kingdom
| | - C Marques
- Universidade Lusófona de Humanidades e Tecnologias, Campo Grande 376, Lisboa 1749-024, Portugal; Centre for Interdisciplinary Research in Animal Health (CIISA), Faculty of Veterinary Medicine, University of Lisbon, Tapada da Ajuda, Lisboa, Portugal
| | - A Vilen
- AniCura Landskrona Smådjursklinik, Föreningsgatan 165, Landskrona 261 51, Sweden
| | - E L Duarte
- Mediterranean Institute for Agriculture, Environment and Development & Departamento de Medicina Veterinária, Escola de Ciências e Tecnologia, Universidade de Évora, Universidade de Évora, Pólo da Mitra Apartado 94, Évora 7006-554, Portugal; ESCMID Study Group for Veterinary Microbiology (ESGVM), Basel, Switzerland
| | - M Dias
- Mediterranean Institute for Agriculture, Environment and Development & Departamento de Medicina Veterinária, Escola de Ciências e Tecnologia, Universidade de Évora, Universidade de Évora, Pólo da Mitra Apartado 94, Évora 7006-554, Portugal
| | - S Dewulf
- Veterinary Epidemiology Unit, Faculty of Veterinary Medicine, Ghent University, Gebouw D4, Salisburylaan 133, Merelbeke, Ghent 9820, Belgium
| | - A Wichtowska
- Department of Fundamental and Preclinical Sciences, Nicolaus Copernicus University, Jurija Gagarina 11, Toruń 87-100, Poland
| | - A Carranza Valencia
- Department of Clinical Veterinary Medicine, Vetsuisse Faculty, Bern University, Länggassstrasse 120, Bern 3012, Switzerland
| | - L Pelligand
- Dept. Comparative Biomedical Sciences, The Royal Veterinary College, University of London, 4 Royal College St, London NW1 0TU, United Kingdom; ESCMID Study Group for Veterinary Microbiology (ESGVM), Basel, Switzerland
| | - E M Broens
- Faculty of Veterinary Medicine, Utrecht University, Yalelaan 1, Utrecht 3584 CL, the Netherlands; ESCMID Study Group for Veterinary Microbiology (ESGVM), Basel, Switzerland
| | - P L Toutain
- Dept. Comparative Biomedical Sciences, The Royal Veterinary College, University of London, 4 Royal College St, London NW1 0TU, United Kingdom; INTHERES, Université de Toulouse, INRAE, ENVT, 23 Chem. des Capelles Entrée n°1, Toulouse 31300, France
| | - M Alishani
- Department of Veterinary Medicine, Faculty of Agriculture and Veterinary, University of Prishtina "Hasan Prishtina", Prishtina 10 000, Kosovo
| | - M L Brennan
- Centre for Evidence-based Veterinary Medicine, The University of Nottingham, Loughborough LE12 5RD, United Kingdom
| | - J S Weese
- Dept of Pathobiology, Ontario Veterinary College, University of Guelph, 419 Gordon St, Guelph, ON N1G 2W1, Canada
| | - L R Jessen
- Department of Veterinary Clinical Sciences, University of Copenhagen, Dyrlaegevej 16, Frederiksberg C 1870, Denmark; ESCMID Study Group for Veterinary Microbiology (ESGVM), Basel, Switzerland
| | - F Allerton
- Willows Veterinary Centre & Referral Service, Solihull B90 4NH, United Kingdom
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5
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Talkhan H, Stewart D, McIntosh T, Ziglam H, Abdulrouf PV, Al-Hail M, Diab M, Cunningham S. Exploring determinants of antimicrobial prescribing behaviour using the Theoretical Domains Framework. Res Social Adm Pharm 2024; 20:401-410. [PMID: 38320948 DOI: 10.1016/j.sapharm.2023.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 12/19/2023] [Accepted: 12/21/2023] [Indexed: 02/08/2024]
Abstract
BACKGROUND Few theoretically-based, qualitative studies have explored determinants of antimicrobial prescribing behaviour in hospitals. Understanding these can promote successful development and implementation of behaviour change interventions (BCIs). OBJECTIVE (s): To use the Theoretical Domains Framework (TDF) to explore determinants of clinicians' antimicrobial prescribing behaviour, identifying barriers (i.e., impediments) and facilitators to appropriate antimicrobial practice. METHODS Semi-structured interviews with purposively-sampled doctors and pharmacists with a wide range of specialties and expertise in Hamad Medical Corporation hospitals in Qatar. Interviews based on previous quantitative research and the TDF were audio-recorded, transcribed and independently analysed by two researchers using the TDF as an initial coding framework. RESULTS Data saturation was achieved after interviewing eight doctors and eight pharmacists. Inter-related determinants of antimicrobial prescribing behaviour linked to ten TDF domains were identified as barriers and facilitators that may contribute to inappropriate or appropriate antimicrobial prescribing. The main barriers identified were around hospital guidelines and electronic system deficiencies (environmental context and resources); knowledge gaps relating to guidelines and appropriate prescribing (knowledge); restricted roles/responsibilities of microbiologists and pharmacists (professional role and identity); challenging antimicrobial prescribing decisions (memory, attention and decision processes); and professional hierarchies and poor multidisciplinary teamworking (social influences). Key facilitators included guidelines compliance (goals and intentions), and participants' beliefs about the consequences of appropriate or inappropriate prescribing. Further education and training, and some changes to guidelines including their accessibility were also considered essential. CONCLUSIONS Antimicrobial prescribing behaviour in hospitals is a complex process influenced by a broad range of determinants including specific barriers and facilitators. The in-depth understanding of this complexity provided by this work may support the development of an effective BCI to promote appropriate antimicrobial stewardship.
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Affiliation(s)
- Hend Talkhan
- School of Pharmacy and Life Sciences, Robert Gordon University, UK.
| | - Derek Stewart
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar.
| | - Trudi McIntosh
- School of Pharmacy and Life Sciences, Robert Gordon University, UK.
| | - Hisham Ziglam
- Infectious Diseases Department, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar.
| | | | - Moza Al-Hail
- Pharmacy Department, Women's Wellness and Research Center, Hamad Medical Corporation, Doha, Qatar.
| | - Mohammad Diab
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar.
| | - Scott Cunningham
- School of Pharmacy and Life Sciences, Robert Gordon University, UK.
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Perez R, Yarrington ME, Deri CR, Smith MJ, Hayes J, Wrenn RH, Moehring RW. Teams in Transition: Increasing Role of Advanced Practice Providers in Antimicrobial Use and Infectious Diseases Consultation. Open Forum Infect Dis 2024; 11:ofae141. [PMID: 38577030 PMCID: PMC10993059 DOI: 10.1093/ofid/ofae141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 03/11/2024] [Indexed: 04/06/2024] Open
Abstract
Background Advanced practice providers (APPs) have taken on increasing responsibilities as primary team members in acute care hospitals, but the impact of this practice shift on antimicrobial prescribing and infectious diseases (ID) consultation requests is unknown. Here we describe longitudinal trends in antimicrobial days of therapy (DOT) and ID consultation by attributed provider type in 3 hospitals. Methods We performed a retrospective time series analysis of antimicrobial use and ID consultation from July 2015 to June 2022 at a major university hospital and 2 community hospitals. We evaluated antimicrobial DOT and ID consultation over time and assessed attribution to 3 groups of providers: attending physicians, trainees, and APPs. We used multinomial logistic regression to measure changes in percentage of DOT and ID consultation across the clinician groups over time using physicians as the referent. Results Baseline distribution of antimicrobial DOT and ID consultation varied by practice setting, but all subgroups showed increases in the proportion attributable to APPs. Large increases were seen in the rate of ID consultation, increasing by >30% during the study period. At our university hospital, by study end >40% of new ID consults and restricted antimicrobial days were attributed to APPs. Conclusions Hospitals had differing baseline patterns of DOT attributed to provider groups, but all experienced increases in DOT attributed to APPs. Similar increases were seen in changes to ID consultation. APPs have increasing involvement in antimicrobial use decisions in the inpatient setting and should be engaged in future antimicrobial stewardship initiatives.
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Affiliation(s)
- Reinaldo Perez
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
- Department of Medicine, Duke Center for Antimicrobial Stewardship and Infection Prevention, Department of Medicine, Durham, North Carolina, USA
| | - Michael E Yarrington
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
- Department of Medicine, Duke Center for Antimicrobial Stewardship and Infection Prevention, Department of Medicine, Durham, North Carolina, USA
| | - Connor R Deri
- Department of Pharmacy, Duke University Medical Center, Durham, North Carolina, USA
| | - Michael J Smith
- Department of Medicine, Duke Center for Antimicrobial Stewardship and Infection Prevention, Department of Medicine, Durham, North Carolina, USA
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA
| | - Jillian Hayes
- Department of Pharmacy, Duke University Medical Center, Durham, North Carolina, USA
| | - Rebekah H Wrenn
- Department of Pharmacy, Duke University Medical Center, Durham, North Carolina, USA
| | - Rebekah W Moehring
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
- Department of Medicine, Duke Center for Antimicrobial Stewardship and Infection Prevention, Department of Medicine, Durham, North Carolina, USA
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Linde-Ozola Z, Classen AY, Giske CG, Göpel S, Eliakim-Raz N, Semret M, Simonsen GS, Vehreschild JJ, Jørgensen SB, Kessel J, Kleppe LKS, Oma DH, Vehreschild MJGT, Vilde A, Dumpis U. Quality, availability and suitability of antimicrobial stewardship guidance: a multinational qualitative study. JAC Antimicrob Resist 2024; 6:dlae039. [PMID: 38486662 PMCID: PMC10939443 DOI: 10.1093/jacamr/dlae039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 02/19/2024] [Indexed: 03/17/2024] Open
Abstract
Background Antimicrobial stewardship (AMS) programmes are established across the world to treat infections efficiently, prioritize patient safety, and reduce the emergence of antimicrobial resistance. One of the core elements of AMS programmes is guidance to support and direct physicians in making efficient, safe and optimal decisions when prescribing antibiotics. To optimize and tailor AMS, we need a better understanding of prescribing physicians' experience with AMS guidance. Objectives To explore the prescribing physicians' user experience, needs and targeted improvements of AMS guidance in hospital settings. Methods Semi-structured interviews were conducted with 36 prescribing physicians/AMS guidance users from hospital settings in Canada, Germany, Israel, Latvia, Norway and Sweden as a part of the international PILGRIM trial. A socioecological model was applied as an overarching conceptual framework for the study. Results Research participants were seeking more AMS guidance than is currently available to them. The most important aspects and targets for improvement of AMS guidance were: (i) quality of guidelines; (ii) availability of infectious diseases specialists; and (iii) suitability of AMS guidance to department context. Conclusions Achieving prudent antibiotic use not only depends on individual and collective levels of commitment to follow AMS guidance but also on the quality, availability and suitability of the guidance itself. More substantial commitment from stakeholders is needed to allocate the required resources for delivering high-quality, available and relevant AMS guidance to make sure that the prescribers' AMS needs are met.
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Affiliation(s)
| | - Annika Y Classen
- Faculty of Medicine, University of Cologne, Cologne, Germany
- Department I for Internal Medicine, University Hospital Cologne, Cologne, Germany
- German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany
| | - Christian G Giske
- Department of Laboratory Medicine, Karolinska Institute, Stockholm, Sweden
- Department of Clinical Microbiology, Karolinska University Hospital, Stockholm, Sweden
| | - Siri Göpel
- Department of Internal Medicine I, Division of infectious diseases, University Hospital Tübingen, Tübingen, Germany
- Clinical Research Unit for Healthcare Associated and Antibiotic Resistant Bacterial Infections, German Centre for Infection Research (DZIF), Tübingen, Germany
| | - Noa Eliakim-Raz
- Internal Medicine E, Rabin Medical Center Beilinson Campus, Petah-Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Makeda Semret
- Infectious Diseases and Medical Microbiology, McGill University Health Centre, Montreal, Canada
| | - Gunnar Skov Simonsen
- Department of Microbiology and Infection Control, University Hospital of North Norway, Tromsø, Norway
- UiT-The Arctic University of Norway, Tromsø, Norway
| | - Jörg Janne Vehreschild
- Faculty of Medicine, University of Cologne, Cologne, Germany
- Department I for Internal Medicine, University Hospital Cologne, Cologne, Germany
- German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany
- Department II of Internal Medicine, Haematology/Oncology, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Silje Bakken Jørgensen
- Department of Medical Microbiology and Infection Control and Department of Emergency Care, Akershus University Hospital, Lørenskog, Norway
| | - Johanna Kessel
- Department of Internal Medicine, Infectious Diseases, Goethe University Frankfurt, Frankfurt Am Main, Germany
| | - Lars Kåre Selland Kleppe
- Department of Infection Prevention and Control, Stavanger University Hospital, Stavanger, Norway
| | - Dorthea Hagen Oma
- Section for Patient Safety, Haukeland University Hospital, Bergen, Norway
| | - Maria J G T Vehreschild
- Faculty of Medicine, University of Cologne, Cologne, Germany
- Department I for Internal Medicine, University Hospital Cologne, Cologne, Germany
- German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany
- Department of Internal Medicine, Infectious Diseases, Goethe University Frankfurt, Frankfurt Am Main, Germany
| | - Aija Vilde
- Faculty of Medicine, University of Latvia, Riga, Latvia
- Pauls Stradins Clinical University Hospital, Riga, Latvia
| | - Uga Dumpis
- Faculty of Medicine, University of Latvia, Riga, Latvia
- Pauls Stradins Clinical University Hospital, Riga, Latvia
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8
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Lee CY, Lai HY, Lee CH, Chen MM, Yau SY. Collaborative clinical reasoning: a scoping review. PeerJ 2024; 12:e17042. [PMID: 38464754 PMCID: PMC10924455 DOI: 10.7717/peerj.17042] [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: 08/25/2023] [Accepted: 02/12/2024] [Indexed: 03/12/2024] Open
Abstract
Background Collaborative clinical reasoning (CCR) among healthcare professionals is crucial for maximizing clinical outcomes and patient safety. This scoping review explores CCR to address the gap in understanding its definition, structure, and implications. Methods A scoping review was undertaken to examine CCR related studies in healthcare. Medline, PsychInfo, SciVerse Scopus, and Web of Science were searched. Inclusion criteria included full-text articles published between 2011 to 2020. Search terms included cooperative, collaborative, shared, team, collective, reasoning, problem solving, decision making, combined with clinical or medicine or medical, but excluded shared decision making. Results A total of 24 articles were identified in the review. The review reveals a growing interest in CCR, with 14 articles emphasizing the decision-making process, five using Multidisciplinary Team-Metric for the Observation of Decision Making (MDTs-MODe), three exploring CCR theory, and two focusing on the problem-solving process. Communication, trust, and team dynamics emerge as key influencers in healthcare decision-making. Notably, only two articles provide specific CCR definitions. Conclusions While decision-making processes dominate CCR studies, a notable gap exists in defining and structuring CCR. Explicit theoretical frameworks, such as those proposed by Blondon et al. and Kiesewetter et al., are crucial for advancing research and understanding CCR dynamics within collaborative teams. This scoping review provides a comprehensive overview of CCR research, revealing a growing interest and diversity in the field. The review emphasizes the need for explicit theoretical frameworks, citing Blondon et al. and Kiesewetter et al. The broader landscape of interprofessional collaboration and clinical reasoning requires exploration.
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Affiliation(s)
- Ching-Yi Lee
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Hung-Yi Lai
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Ching-Hsin Lee
- Department of Radiation Oncology, Proton and Radiation Therapy Center, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Mi-Mi Chen
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Sze-Yuen Yau
- (CG-MERC) Chang Gung Medical Education Research Centre, Linkou, Taoyuan, Taiwan
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Bonaconsa C, Mbamalu O, Surendran S, George A, Mendelson M, Charani E. Optimizing infection control and antimicrobial stewardship bedside discussion: a scoping review of existing evidence on effective healthcare communication in hospitals. Clin Microbiol Infect 2024; 30:336-352. [PMID: 38101471 DOI: 10.1016/j.cmi.2023.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 11/15/2023] [Accepted: 12/08/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND The link between healthcare worker (HCW) communication, teamwork and patient safety is well-established. Infection prevention and control (IPC) and antimicrobial stewardship (AMS) require multidisciplinary teamwork and communication. OBJECTIVES We conducted a scoping review of published evidence on effective mechanisms of HCW team communication in hospitals with the intention of transferring and tailoring learning to IPC and AMS team communication. METHODS PubMed, Scopus, Web of Science, and CINAHL were searched for studies that investigated HCW team communication across in-hospital patient pathways. Studies published between 2000 and 2021 that provided evidence on/or described the effect of communication on team and patient outcomes in hospital were included. Through a process of inductive qualitative content analysis, key themes in the included studies were identified. RESULTS Of 537 studies identified, 53 (from high-income countries) were included in the data extraction. Fifty one percent (27/53) of studies were conducted in high acuity settings e.g., intensive care units. Standardizing or structuring the content and/or process of team communication was the most common goal of interventions (34/53, 64%). The key outcome measures were either team communication focused (25/34,74%) or patient and process outcome focused (8/34, 24%), such as reduced length of mechanical ventilation days, length of hospital stay, and shorter empiric antibiotic duration. Four studies (4/53, 8%) associated improved communication with positive IPC and AMS outcome measures. Mixed method intervention studies primarily facilitated collaborative input from HCWs and applied structures to standardize the content of patient care discussions, whereas observational studies describe component of team communication. CONCLUSIONS A communication strategy that formalizes input from multidisciplinary team members can lead to optimized and consistent clinical discussion including in IPC and AMS-related care. Although we were unable to assess the effectiveness of interventions, the existing evidence suggests that optimizing team communication can have a positive effect on infection-related patient outcomes.
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Affiliation(s)
- Candice Bonaconsa
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa.
| | - Oluchi Mbamalu
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Surya Surendran
- Department of Infection Control and Epidemiology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham University, Kochi, Kerala, India; Department of Health Systems and Equity, The George Institute for Global Health, Hyderabad, India
| | - Anu George
- Department of Infection Control and Epidemiology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham University, Kochi, Kerala, India
| | - Marc Mendelson
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Esmita Charani
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa; Department of Infection Control and Epidemiology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham University, Kochi, Kerala, India; Faculty of Health and Life Sciences, University of Liverpool, Liverpool, United Kingdom
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Blissett S, Skinner J, Banner H, Cristancho S, Taylor T. How do residents respond to uncertainty with peers and supervisors in multidisciplinary teams? Insights from simulations with epistemic fidelity. Adv Simul (Lond) 2024; 9:8. [PMID: 38347654 PMCID: PMC10863229 DOI: 10.1186/s41077-024-00281-8] [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: 08/31/2023] [Accepted: 01/30/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND Residents struggle to express clinical uncertainty, often exhibiting negative cognitive, behavioral, and emotional responses to uncertainty when engaging with patients or supervisors. However, the Integrative Model of Uncertainty Tolerance posits that individuals may have positive or negative responses to perceived uncertainty. Situational characteristics, such as interactions with other health professionals, can impact whether the response is positive or negative. The team context in which residents interact with resident peers and supervisors could represent varying situational characteristics that enable a spectrum of responses to uncertainty. Understanding the situational characteristics of multidisciplinary teams that allow residents to display positive responses to perceived uncertainty could inform strategies to foster positive responses to uncertainty in other contexts. We explored resident responses to perceived uncertainty in a simulated multidisciplinary team context. METHODS A simulation-primed qualitative inquiry approach was used. Fourteen residents from Cardiology and Obstetrics and Gynecology participated in simulation scenarios involving pregnant patients with heart disease. We incorporated epistemic fidelity through the deliberate inclusion of ambiguity and complexity to prompt uncertainty. Audio recordings of debriefing sessions were analyzed using directed content analysis. RESULTS Residents recognized that uncertainty is unavoidable, and positive responses to uncertainty are crucial to team dynamics and patient safety. While residents had positive responses to expressing uncertainty to peers, they had predominantly negative responses to expressing uncertainty to supervisors. Predominant negative response to supervisors related to judgement from supervisors, and impacts on perceived trustworthiness or independence. Although residents recognized expressing uncertainty to a supervisor could identify opportunities for learning and resolve their uncertainty, the negative responses overshadowed the positive responses. Residents highly valued instances in which supervisors were forthcoming about their own uncertainty. CONCLUSIONS Through participation in simulations with epistemic fidelity, residents reflected on how they perceive and respond to uncertainty in multidisciplinary teams. Our findings emphasize the role of situational characteristics, particularly peers and supervisors, in moderating responses to perceived uncertainty. The productive discussions around responses to uncertainty in debriefing sessions suggest further studies of multidisciplinary simulations could enhance our understanding of how uncertainty is expressed, and potentially be used as an instructional intervention to promote positive responses to uncertainty.
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Affiliation(s)
- Sarah Blissett
- Division of Cardiology, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada.
- Centre for Education Research and Innovation, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada.
| | - Jamila Skinner
- Schulich School of Medicine and Dentistry, London, ON, Canada
| | - Harrison Banner
- Department of Obstetrics and Gynecology, Schulich School of Medicine and Dentistry, London, ON, Canada
| | - Sayra Cristancho
- Centre for Education Research and Innovation, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Taryn Taylor
- Centre for Education Research and Innovation, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Department of Obstetrics and Gynecology, Schulich School of Medicine and Dentistry, London, ON, Canada
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11
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Hernandez SE, Solomon D, Moon J, Parmasad V, Wiegmann D, Bennett NT, Ferren RS, Fitzsimmons AJ, Lepak AJ, O'Horo JC, Pop-Vicas AE, Schulz LT, Safdar N. Understanding clinical implementation coordinators' experiences in deploying evidence-based interventions. Am J Health Syst Pharm 2024; 81:120-128. [PMID: 37897218 DOI: 10.1093/ajhp/zxad272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Indexed: 10/29/2023] Open
Abstract
PURPOSE The fluoroquinolone restriction for the prevention of Clostridioides difficile infection (FIRST) trial is a multisite clinical study in which sites carry out a preauthorization process via electronic health record-based best-practice alert (BPA) to optimize the use of fluoroquinolone antibiotics in acute care settings. Our research team worked closely with clinical implementation coordinators to facilitate the dissemination and implementation of this evidence-based intervention. Clinical implementation coordinators within the antibiotic stewardship team (AST) played a pivotal role in the implementation process; however, considerable research is needed to further understand their role. In this study, we aimed to (1) describe the roles and responsibilities of clinical implementation coordinators within ASTs and (2) identify facilitators and barriers coordinators experienced within the implementation process. METHODS We conducted a directed content analysis of semistructured interviews, implementation diaries, and check-in meetings utilizing the conceptual framework of middle managers' roles in innovation implementation in healthcare from Urquhart et al. RESULTS Clinical implementation coordinators performed a variety of roles vital to the implementation's success, including gathering and compiling information for BPA design, preparing staff, organizing meetings, connecting relevant stakeholders, evaluating clinical efficacy, and participating in the innovation as clinicians. Coordinators identified organizational staffing models and COVID-19 interruptions as the main barriers. Facilitators included AST empowerment, positive relationships with staff and oversight/governance committees, and using diverse implementation strategies. CONCLUSION When implementing healthcare innovations, clinical implementation coordinators facilitated the implementation process through their roles and responsibilities and acted as strategic partners in improving the adoption and sustainability of a fluoroquinolone preauthorization protocol.
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Affiliation(s)
- Sara E Hernandez
- School of Pharmacy, University of Wisconsin-Madison, Madison, WI, USA
| | - Demetrius Solomon
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, WI, USA
| | - Jukrin Moon
- School of Pharmacy, University of Wisconsin-Madison, Madison, WI, USA
| | - Vishala Parmasad
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Douglas Wiegmann
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, WI, USA
| | - Nick T Bennett
- Antimicrobial Stewardship Program, Saint Luke's Health System, Kansas City, MO, USA
| | - Ryan S Ferren
- University of Texas Medical Branch, Galveston, TX, USA
| | - Alec J Fitzsimmons
- Department of Medical Research, Gundersen Health System, La Crosse, WI, USA
| | - Alexander J Lepak
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - John C O'Horo
- Mayo Foundation for Medical Education and Research, Rochester, MN, USA
| | - Aurora E Pop-Vicas
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Lucas T Schulz
- Department of Pharmacy, University of Wisconsin Health, Madison, WI, USA
| | - Nasia Safdar
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
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12
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Arenz L, Porger A, De Michel M, Weber A, Jung J, Horns H, Gscheidle S, Weiglein T, Pircher J, Becker-Lienau J, Horster S, Klein M, Draenert R. Effect and sustainability of a stepwise implemented multidisciplinary antimicrobial stewardship programme in a university hospital emergency department. JAC Antimicrob Resist 2024; 6:dlae026. [PMID: 38410248 PMCID: PMC10895698 DOI: 10.1093/jacamr/dlae026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 02/02/2024] [Indexed: 02/28/2024] Open
Abstract
Objectives To explore effectiveness and sustainability of guideline adherence and antibiotic consumption after establishing treatment guidelines and initiating antimicrobial stewardship (AMS) ward rounds in a university hospital emergency department (ED). Methods Data were gathered retrospectively from 2017 to 2021 in the LMU University Hospital in Munich, Germany. Four time periods were compared: P1 (pre-intervention period); P2 (distribution of guideline pocket cards); P3 (reassessment after 3 years); and P4 (refresher of guideline pocket cards and additional daily AMS ward rounds for different medical disciplines). Primary outcome was adherence to guideline pocket cards for community-acquired pneumonia, cystitis, pyelonephritis and COVID-19-associated bacterial pneumonia. Secondary outcomes were reduction in antibiotic consumption and adherence to AMS specialist recommendations. Results The study included 1324 patients. Guideline adherence increased in P2 for each of the infectious diseases entities. After 3 years (P3), guideline adherence decreased again, but was mostly on a higher level than in P1. AMS ward rounds resulted in an additional increase in guideline adherence (P1/P2: 47% versus 58.6%, P = 0.005; P2/P3: 58.6% versus 57.3%, P = 0.750; P3/P4: 57.3% versus 72.5%, P < 0.001). Adherence increased significantly, not only during workdays but also on weekends/nightshifts. Adherence to AMS specialist recommendations was excellent (91.3%). We observed an increase in use of narrow-spectrum antibiotics and a decrease in the application of fluoroquinolones and cephalosporins. Conclusions Establishing treatment guidelines in the ED is effective. However, positive effects can be diminished over time. Daily AMS ward rounds are useful, not only to restore but to further increase guideline adherence significantly.
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Affiliation(s)
- Lukas Arenz
- Antibiotic Stewardship Programme, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
- Department of Medicine II, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
| | - Annika Porger
- Antibiotic Stewardship Programme, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
| | - Michaela De Michel
- Antibiotic Stewardship Programme, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
| | - Alexandra Weber
- Antibiotic Stewardship Programme, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
- Department of Hospital Pharmacy, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
| | - Jette Jung
- Antibiotic Stewardship Programme, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
- Max-von-Pettenkofer-Institute Munich, LMU Munich, Elisabeth-Winterhalter-Weg 6, 81377 München, Germany
| | - Heidi Horns
- Antibiotic Stewardship Programme, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
| | - Sandra Gscheidle
- Antibiotic Stewardship Programme, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
- Department of Hospital Pharmacy, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
| | - Tobias Weiglein
- Department of Medicine III, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
- Emergency Department, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
| | - Joachim Pircher
- Emergency Department, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
- Department of Medicine I, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
| | - Johanna Becker-Lienau
- Emergency Department, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
- Department of Orthopedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
| | - Sophia Horster
- Emergency Department, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
| | - Matthias Klein
- Emergency Department, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
- Department of Neurology, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
| | - Rika Draenert
- Antibiotic Stewardship Programme, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
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13
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Van Dort BA, Ritchie A, Penm J, Gray TJ, Ronnachit A, Baysari MT. A tale of 2 digital hospitals: A qualitative study of antimicrobial stewardship teams. Br J Clin Pharmacol 2024. [PMID: 38294057 DOI: 10.1111/bcp.16001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 12/11/2023] [Accepted: 01/02/2024] [Indexed: 02/01/2024] Open
Abstract
AIMS We aim to examine and understand the work processes of antimicrobial stewardship (AMS) teams across 2 hospitals that use the same digital intervention, and to identify the barriers and enablers to effective AMS in each setting. METHODS Employing a contextual inquiry approach informed by the Systems Engineering Initiative for Patient Safety (SEIPS) model, observations and semistructured interviews were conducted with AMS team members (n = 15) in 2 Australian hospitals. Qualitative data analysis was conducted, mapping themes to the SEIPS framework. RESULTS Both hospitals utilized similar systems, however, they displayed variations in AMS processes, particularly in postprescription review, interdepartmental AMS meetings and the utilization of digital tools. An antimicrobial dashboard was available at both hospitals but was utilized more at the hospital where the AMS team members were involved in the dashboard's development, and there were user champions. At the hospital where the dashboard was utilized less, participants were unaware of key features, and interoperability issues were observed. Establishing strong relationships between the AMS team and prescribers emerged as key to effective AMS at both hospitals. However, organizational and cultural differences were found, with 1 hospital reporting insufficient support from executive leadership, increased prescriber autonomy and resource constraints. CONCLUSION Organizational and cultural elements, such as executive support, resource allocation and interdepartmental relationships, played a crucial role in achieving AMS goals. System interoperability and user champions further promoted the adoption of digital tools, potentially improving AMS outcomes through increased user engagement and acceptance.
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Affiliation(s)
- Bethany A Van Dort
- School of Medical Sciences, Faculty of Medicine and Health, Charles Perkins Centre, Biomedical Informatics and Digital Health, The University of Sydney, Sydney, Australia
| | - Angus Ritchie
- Health Informatics Unit, Sydney Local Health District, Camperdown, Australia
- Faculty of Medicine and Health, Concord Clinical School, The University of Sydney, Sydney, Australia
| | - Jonathan Penm
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Department of Pharmacy, Prince of Wales Hospital, Randwick, Australia
| | - Timothy J Gray
- Department of Infectious Diseases and Microbiology, Concord Repatriation General Hospital, Sydney, Australia
| | - Amrita Ronnachit
- Department of Infectious Diseases and Microbiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Melissa T Baysari
- School of Medical Sciences, Faculty of Medicine and Health, Charles Perkins Centre, Biomedical Informatics and Digital Health, The University of Sydney, Sydney, Australia
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Howard A, Reza N, Aston S, Woods B, Gerada A, Buchan I, Hope W, Märtson AG. Antimicrobial treatment imprecision: an outcome-based model to close the data-to-action loop. THE LANCET. INFECTIOUS DISEASES 2024; 24:e47-e58. [PMID: 37660712 DOI: 10.1016/s1473-3099(23)00367-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 06/01/2023] [Accepted: 06/01/2023] [Indexed: 09/05/2023]
Abstract
Health-care systems, food supply chains, and society in general are threatened by the inexorable rise of antimicrobial resistance. This threat is driven by many factors, one of which is inappropriate antimicrobial treatment. The ability of policy makers and leaders in health care, public health, regulatory agencies, and research and development to deliver frameworks for appropriate, sustainable antimicrobial treatment is hampered by a scarcity of tangible outcome-based measures of the damage it causes. In this Personal View, a mathematically grounded, outcome-based measure of antimicrobial treatment appropriateness, called imprecision, is proposed. We outline a framework for policy makers and health-care leaders to use this metric to deliver more effective antimicrobial stewardship interventions to future patient pathways. This will be achieved using learning antimicrobial systems built on public and practitioner engagement; solid implementation science; advances in artificial intelligence; and changes to regulation, research, and development. The outcomes of this framework would be more ecologically and organisationally sustainable patterns of antimicrobial development, regulation, and prescribing. We discuss practical, ethical, and regulatory considerations involved in the delivery of novel antimicrobial drug development, and policy and patient pathways built on artificial intelligence-augmented measures of antimicrobial treatment imprecision.
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Affiliation(s)
- Alex Howard
- Department of Antimicrobial Pharmacodynamics and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK; Department of Infection and Immunity, Liverpool Clinical Laboratories, Liverpool University Hospitals NHS Foundation Trust, Royal Liverpool Site, Liverpool, UK.
| | - Nada Reza
- Department of Antimicrobial Pharmacodynamics and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Stephen Aston
- Department of Antimicrobial Pharmacodynamics and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Beth Woods
- Centre for Health Economics, University of York, Heslington, York, UK
| | - Alessandro Gerada
- Department of Antimicrobial Pharmacodynamics and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK; Department of Infection and Immunity, Liverpool Clinical Laboratories, Liverpool University Hospitals NHS Foundation Trust, Royal Liverpool Site, Liverpool, UK
| | - Iain Buchan
- Department of Public Health, Policy & Systems, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - William Hope
- Department of Antimicrobial Pharmacodynamics and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK; Department of Infection and Immunity, Liverpool Clinical Laboratories, Liverpool University Hospitals NHS Foundation Trust, Royal Liverpool Site, Liverpool, UK
| | - Anne-Grete Märtson
- Department of Antimicrobial Pharmacodynamics and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
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15
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Hand J, Imlay H. Antimicrobial Stewardship in Immunocompromised Patients: Current State and Future Opportunities. Infect Dis Clin North Am 2023; 37:823-851. [PMID: 37741735 DOI: 10.1016/j.idc.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/25/2023]
Abstract
Immunocompromised (IC) patients are high risk for complications due to a high rate of antibiotic exposure. Antimicrobial stewardship interventions targeted to IC patients can be challenging due to limited data in this population and a high risk of severe infection-related outcomes. Here, the authors review immunocompromised antimicrobial stewardship barriers, metrics, and opportunities for antimicrobial use and testing optimization. Last, the authors highlight future steps in the field.
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Affiliation(s)
- Jonathan Hand
- Ochsner Health, New Orleans, LA, USA; University of Queensland School of Medicine, Ochsner Clinical School
| | - Hannah Imlay
- University of Utah Department of Internal Medicine, Salt Lake City, UT, USA.
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Kassamali Escobar Z, Shively NR. Health System and Tele-Antimicrobial Stewardship: The Role of Building Networks. Infect Dis Clin North Am 2023; 37:873-900. [PMID: 37657974 DOI: 10.1016/j.idc.2023.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/03/2023]
Abstract
Tele-antimicrobial stewardship programs (tele-ASPs) use technology and remote access to resources and clinical expertise to expand antimicrobial services within and outside of health systems. Models of tele-ASPs are workforce multiplying and workforce extending, depending on how they are structured. Building rapport and strong interpersonal networks are essential for successful ASPs. The available evidence suggests that an optimal model for tele-ASP includes hands-on involvement from remote infectious disease (ID) expertise with implementation by local pharmacists. However, this model remains limited by the available time and cost of ID-trained specialists.
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Affiliation(s)
- Zahra Kassamali Escobar
- University of Washington Center for Stewardship in Medicine, Seattle, WA, USA; Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, 825 Eastlake Avenue, Mail Stop G5-900, P.O. Box 19023, Seattle, WA 98109, USA
| | - Nathan R Shively
- Division of Infectious Diseases, Allegheny Health Network, 320 E North Avenue, Fourth Floor, East Wing, Suite 406, Pittsburgh, PA 15212, USA.
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Tjilos M, Drainoni ML, Burrowes SAB, Butler JM, Damschroder LJ, Bidwell Goetz M, Madaras-Kelly K, Reardon CM, Samore MH, Shen J, Stenehjem EA, Zhang Y, Barlam TF. A qualitative evaluation of frontline clinician perspectives toward antibiotic stewardship programs. Infect Control Hosp Epidemiol 2023; 44:1995-2001. [PMID: 36987859 PMCID: PMC10755145 DOI: 10.1017/ice.2023.35] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 02/02/2023] [Accepted: 02/04/2023] [Indexed: 03/30/2023]
Abstract
OBJECTIVE To examine the perspectives of caregivers that are not part of the antibiotic stewardship program (ASP) leadership team (eg, physicians, nurses, and clinical pharmacists), but who interact with ASPs in their role as frontline healthcare workers. DESIGN Qualitative semistructured interviews. SETTING The study was conducted in 2 large national healthcare systems including 7 hospitals in the Veterans' Health Administration and 4 hospitals in Intermountain Healthcare. PARTICIPANTS We interviewed 157 participants. The current analysis includes 123 nonsteward clinicians: 47 physicians, 26 pharmacists, 29 nurses, and 21 hospital leaders. METHODS Interviewers utilized a semistructured interview guide based on the Consolidated Framework for Implementation Research (CFIR), which was tailored to the participant's role in the hospital as it related to ASPs. Qualitative analysis was conducted using a codebook based on the CFIR. RESULTS We identified 4 primary perspectives regarding ASPs. (1) Non-ASP pharmacists considered antibiotic stewardship activities to be a high priority despite the added burden to work duties: (2) Nurses acknowledged limited understanding of ASP activities or involvement with these programs; (3) Physicians criticized ASPs for their restrictions on clinical autonomy and questioned the ability of antibiotic stewards to make recommendations without the full clinical picture; And (4) hospital leaders expressed support for ASPs and recognized the unique challenges faced by non-ASP clinical staff. CONCLUSION Further understanding these differing perspectives of ASP implementation will inform possible ways to improve ASP implementation across clinical roles.
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Affiliation(s)
- Maria Tjilos
- Department of Community Health Sciences, School of Public Health, Boston University, BostonMassachusetts
| | - Mari-Lynn Drainoni
- Section of Infectious Diseases, Department of Medicine, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
- Department of Health Law, Policy and Management, School of Public Health, Boston University, Boston, Massachusetts
- Evans Center for Implementation and Improvement Sciences, Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
| | - Shana A. B. Burrowes
- Section of Infectious Diseases, Department of Medicine, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
| | - Jorie M. Butler
- Division of Geriatrics, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
- Geriatric Education and Clinical Center and IDEAS Center of Innovation, Veterans’ Affairs (VA) Salt Lake City Health Care System, Salt Lake City, Utah
| | - Laura J. Damschroder
- VA Center for Clinical Management Research, Department of Veterans’ Affairs, Ann Arbor, Michigan
| | - Matthew Bidwell Goetz
- VA Greater Los Angeles Healthcare System, Los Angeles, California
- David Geffen School of Medicine, UCLA, Los Angeles, California
| | - Karl Madaras-Kelly
- Boise VA Medical Center, Boise, Idaho
- College of Pharmacy, Idaho State University, MeridianIdaho
| | - Caitlin M. Reardon
- VA Center for Clinical Management Research, Department of Veterans’ Affairs, Ann Arbor, Michigan
| | - Matthew H. Samore
- IDEAS Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, Utah
- Divison of Epidemiology, Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Jincheng Shen
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah
| | - Edward A. Stenehjem
- Division of Infectious Diseases and Epidemiology, Intermountain Healthcare, Salt Lake City, Utah
| | - Yue Zhang
- Divison of Epidemiology, Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Tamar F. Barlam
- Section of Infectious Diseases, Department of Medicine, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
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Wasson MK, Luther VP, Armstrong WS, Schwartz BS, Shnekendorf R, Logan A, Bennani K, Spicer JO. Skills, Not Just Knowledge: Infectious Diseases Fellows' Recommendations Regarding Antimicrobial Stewardship Training. Clin Infect Dis 2023; 77:1265-1272. [PMID: 37310036 DOI: 10.1093/cid/ciad358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/23/2023] [Accepted: 06/08/2023] [Indexed: 06/14/2023] Open
Abstract
BACKGROUND Antimicrobial stewardship (AS) is an important topic in infectious diseases (ID) training, yet many ID fellowships lack formal training, and little is known about fellows' learning preferences. METHODS We conducted 24 in-depth interviews with ID fellows across the United States during 2018 and 2019 to explore their experiences with and preferences for AS education during fellowship. Interviews were transcribed, deidentified, and analyzed to identify themes. RESULTS Fellows had variable exposure to AS before and during fellowship, which impacted their knowledge about and attitude toward stewardship as a career; however, all fellows expressed the importance of learning general stewardship principles during fellowship. Some fellows' training included mandatory stewardship lectures and/or rotations, but most fellows felt their primary stewardship learning occurred through informal experiences in the clinical setting, such as holding the antimicrobial approval pager. Fellows expressed a preference for a standardized, structured curriculum that included in-person practical, interactive discussions with multidisciplinary faculty along with the opportunity to practice and apply their skills; however, they emphasized that time needed to be set aside for those educational activities. Although they wanted to learn the evidence and rationale for stewardship recommendations, they especially wanted training in and feedback on how to communicate stewardship recommendations to other health professionals, particularly in the setting of conflict. CONCLUSIONS ID fellows believe that standardized AS curricula should be included in their fellowship training, and they prefer structured, practical, and interactive learning experiences.
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Affiliation(s)
- Megan K Wasson
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - Vera P Luther
- Division of Infectious Diseases, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Wendy S Armstrong
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Brian S Schwartz
- Division of Infectious Diseases, Department of Medicine, University of California, San Francisco, California, USA
| | | | - Ashleigh Logan
- Infectious Diseases Society of America, Arlington, Virginia, USA
| | - Kenza Bennani
- Infectious Diseases Society of America, Arlington, Virginia, USA
| | - Jennifer O Spicer
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
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Sartelli M, Barie PS, Coccolini F, Abbas M, Abbo LM, Abdukhalilova GK, Abraham Y, Abubakar S, Abu-Zidan FM, Adebisi YA, Adamou H, Afandiyeva G, Agastra E, Alfouzan WA, Al-Hasan MN, Ali S, Ali SM, Allaw F, Allwell-Brown G, Amir A, Amponsah OKO, Al Omari A, Ansaloni L, Ansari S, Arauz AB, Augustin G, Awazi B, Azfar M, Bah MSB, Bala M, Banagala ASK, Baral S, Bassetti M, Bavestrello L, Beilman G, Bekele K, Benboubker M, Beović B, Bergamasco MD, Bertagnolio S, Biffl WL, Blot S, Boermeester MA, Bonomo RA, Brink A, Brusaferro S, Butemba J, Caínzos MA, Camacho-Ortiz A, Canton R, Cascio A, Cassini A, Cástro-Sanchez E, Catarci M, Catena R, Chamani-Tabriz L, Chandy SJ, Charani E, Cheadle WG, Chebet D, Chikowe I, Chiara F, Cheng VCC, Chioti A, Cocuz ME, Coimbra R, Cortese F, Cui Y, Czepiel J, Dasic M, de Francisco Serpa N, de Jonge SW, Delibegovic S, Dellinger EP, Demetrashvili Z, De Palma A, De Silva D, De Simone B, De Waele J, Dhingra S, Diaz JJ, Dima C, Dirani N, Dodoo CC, Dorj G, Duane TM, Eckmann C, Egyir B, Elmangory MM, Enani MA, Ergonul O, Escalera-Antezana JP, Escandon K, Ettu AWOO, Fadare JO, Fantoni M, Farahbakhsh M, Faro MP, Ferreres A, Flocco G, Foianini E, Fry DE, Garcia AF, Gerardi C, Ghannam W, Giamarellou H, Glushkova N, Gkiokas G, Goff DA, Gomi H, Gottfredsson M, Griffiths EA, Guerra Gronerth RI, Guirao X, Gupta YK, Halle-Ekane G, Hansen S, Haque M, Hardcastle TC, Hayman DTS, Hecker A, Hell M, Ho VP, Hodonou AM, Isik A, Islam S, Itani KMF, Jaidane N, Jammer I, Jenkins DR, Kamara IF, Kanj SS, Jumbam D, Keikha M, Khanna AK, Khanna S, Kapoor G, Kapoor G, Kariuki S, Khamis F, Khokha V, Kiggundu R, Kiguba R, Kim HB, Kim PK, Kirkpatrick AW, Kluger Y, Ko WC, Kok KYY, Kotecha V, Kouma I, Kovacevic B, Krasniqi J, Krutova M, Kryvoruchko I, Kullar R, Labi KA, Labricciosa FM, Lakoh S, Lakatos B, Lansang MAD, Laxminarayan R, Lee YR, Leone M, Leppaniemi A, Hara GL, Litvin A, Lohsiriwat V, Machain GM, Mahomoodally F, Maier RV, Majumder MAA, Malama S, Manasa J, Manchanda V, Manzano-Nunez R, Martínez-Martínez L, Martin-Loeches I, Marwah S, Maseda E, Mathewos M, Maves RC, McNamara D, Memish Z, Mertz D, Mishra SK, Montravers P, Moro ML, Mossialos E, Motta F, Mudenda S, Mugabi P, Mugisha MJM, Mylonakis E, Napolitano LM, Nathwani D, Nkamba L, Nsutebu EF, O’Connor DB, Ogunsola S, Jensen PØ, Ordoñez JM, Ordoñez CA, Ottolino P, Ouedraogo AS, Paiva JA, Palmieri M, Pan A, Pant N, Panyko A, Paolillo C, Patel J, Pea F, Petrone P, Petrosillo N, Pintar T, Plaudis H, Podda M, Ponce-de-Leon A, Powell SL, Puello-Guerrero A, Pulcini C, Rasa K, Regimbeau JM, Rello J, Retamozo-Palacios MR, Reynolds-Campbell G, Ribeiro J, Rickard J, Rocha-Pereira N, Rosenthal VD, Rossolini GM, Rwegerera GM, Rwigamba M, Sabbatucci M, Saladžinskas Ž, Salama RE, Sali T, Salile SS, Sall I, Kafil HS, Sakakushev BE, Sawyer RG, Scatizzi M, Seni J, Septimus EJ, Sganga G, Shabanzadeh DM, Shelat VG, Shibabaw A, Somville F, Souf S, Stefani S, Tacconelli E, Tan BK, Tattevin P, Rodriguez-Taveras C, Telles JP, Téllez-Almenares O, Tessier J, Thang NT, Timmermann C, Timsit JF, Tochie JN, Tolonen M, Trueba G, Tsioutis C, Tumietto F, Tuon FF, Ulrych J, Uranues S, van Dongen M, van Goor H, Velmahos GC, Vereczkei A, Viaggi B, Viale P, Vila J, Voss A, Vraneš J, Watkins RR, Wanjiru-Korir N, Waworuntu O, Wechsler-Fördös A, Yadgarova K, Yahaya M, Yahya AI, Xiao Y, Zakaria AD, Zakrison TL, Zamora Mesia V, Siquini W, Darzi A, Pagani L, Catena F. Ten golden rules for optimal antibiotic use in hospital settings: the WARNING call to action. World J Emerg Surg 2023; 18:50. [PMID: 37845673 PMCID: PMC10580644 DOI: 10.1186/s13017-023-00518-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 09/23/2023] [Indexed: 10/18/2023] Open
Abstract
Antibiotics are recognized widely for their benefits when used appropriately. However, they are often used inappropriately despite the importance of responsible use within good clinical practice. Effective antibiotic treatment is an essential component of universal healthcare, and it is a global responsibility to ensure appropriate use. Currently, pharmaceutical companies have little incentive to develop new antibiotics due to scientific, regulatory, and financial barriers, further emphasizing the importance of appropriate antibiotic use. To address this issue, the Global Alliance for Infections in Surgery established an international multidisciplinary task force of 295 experts from 115 countries with different backgrounds. The task force developed a position statement called WARNING (Worldwide Antimicrobial Resistance National/International Network Group) aimed at raising awareness of antimicrobial resistance and improving antibiotic prescribing practices worldwide. The statement outlined is 10 axioms, or "golden rules," for the appropriate use of antibiotics that all healthcare workers should consistently adhere in clinical practice.
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McIntyre MT, Saha S, Morris AM, Lapointe-Shaw L, Tang T, Weinerman A, Fralick M, Agarwal A, Verma A, Razak F. Physician antimicrobial prescribing and patient outcomes on general medical wards: a multicentre retrospective cohort study. CMAJ 2023; 195:E1065-E1074. [PMID: 37604522 PMCID: PMC10442238 DOI: 10.1503/cmaj.221732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2023] [Indexed: 08/23/2023] Open
Abstract
BACKGROUND Variability in antimicrobial prescribing may indicate an opportunity for improvement in antimicrobial use. We sought to measure physician-level antimicrobial prescribing in adult general medical wards, assess the contribution of patient-level factors to antimicrobial prescribing and evaluate the association between antimicrobial prescribing and clinical outcomes. METHODS Using the General Medicine Inpatient Initiative (GEMINI) database, we conducted a retrospective cohort study of physician-level volume and spectrum of antimicrobial prescribing in adult general medical wards in 4 academic teaching hospitals in Toronto, Ontario, between April 2010 and December 2019. We stratified physicians into quartiles by hospital site based on volume of antimicrobial prescribing (days of therapy per 100 patient-days and antimicrobial-free days) and antibacterial spectrum (modified spectrum score). The modified spectrum score assigns a value to each antibacterial agent based on the breadth of coverage. We assessed patient-level differences among physician quartiles using age, sex, Laboratory-based Acute Physiology Score, discharge diagnosis and Charlson Comorbidity Index. We evaluated the association of clinical outcomes (in-hospital 30-day mortality, length of stay, intensive care unit [ICU] transfer and hospital readmission) with antimicrobial volume and spectrum using multilevel modelling. RESULTS The cohort consisted of 124 physicians responsible for 124 158 hospital admissions. The median physician-level volume of antimicrobial prescribing was 56.1 (interquartile range 51.7-67.5) days of therapy per 100 patient-days. We did not find any differences in baseline patient characteristics by physician prescribing quartile. The difference in mean prescribing between quartile 4 and quartile 1 was 15.8 days of therapy per 100 patient-days (95% confidence interval [CI] 9.6-22.0), representing 30% higher antimicrobial prescribing in the fourth quartile than the first quartile. Patient in-hospital deaths, length of stay, ICU transfer and hospital readmission did not differ by physician quartile. In-hospital mortality was higher among patients cared for by prescribers with higher modified spectrum scores (odds ratio 1.13, 95% CI 1.04-1.24). INTERPRETATION We found that physician-level variability in antimicrobial prescribing was not associated with differences in patient characteristics or outcomes in academic general medicine wards. These findings provide support for considering the lowest quartile of physician antimicrobial prescribing within each hospital as a target for antimicrobial stewardship.
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Affiliation(s)
- Mark T McIntyre
- Sinai Health (McIntyre, Fralick), Toronto, Ont.; Leslie Dan Faculty of Pharmacy (McIntyre), University of Toronto; Li Ka Shing Knowledge Institute (Saha, Verma, Razak), St. Michael's Hospital, Toronto, Ont.; Department of Social and Behavioral Sciences (Saha), Harvard T.H. Chan School of Public Health, Boston, Mass.; Department of Medicine (Morris, Lapointe-Shaw, Weinerman, Fralick, Verma, Razak), University of Toronto; Department of Medicine (Morris), Mount Sinai Hospital and University Health Network; Department of Medicine (Lapointe-Shaw), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Weinerman), Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Agarwal); Department of Medicine (Agarwal), McMaster University, Hamilton, Ont.
| | - Sudipta Saha
- Sinai Health (McIntyre, Fralick), Toronto, Ont.; Leslie Dan Faculty of Pharmacy (McIntyre), University of Toronto; Li Ka Shing Knowledge Institute (Saha, Verma, Razak), St. Michael's Hospital, Toronto, Ont.; Department of Social and Behavioral Sciences (Saha), Harvard T.H. Chan School of Public Health, Boston, Mass.; Department of Medicine (Morris, Lapointe-Shaw, Weinerman, Fralick, Verma, Razak), University of Toronto; Department of Medicine (Morris), Mount Sinai Hospital and University Health Network; Department of Medicine (Lapointe-Shaw), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Weinerman), Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Agarwal); Department of Medicine (Agarwal), McMaster University, Hamilton, Ont
| | - Andrew M Morris
- Sinai Health (McIntyre, Fralick), Toronto, Ont.; Leslie Dan Faculty of Pharmacy (McIntyre), University of Toronto; Li Ka Shing Knowledge Institute (Saha, Verma, Razak), St. Michael's Hospital, Toronto, Ont.; Department of Social and Behavioral Sciences (Saha), Harvard T.H. Chan School of Public Health, Boston, Mass.; Department of Medicine (Morris, Lapointe-Shaw, Weinerman, Fralick, Verma, Razak), University of Toronto; Department of Medicine (Morris), Mount Sinai Hospital and University Health Network; Department of Medicine (Lapointe-Shaw), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Weinerman), Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Agarwal); Department of Medicine (Agarwal), McMaster University, Hamilton, Ont
| | - Lauren Lapointe-Shaw
- Sinai Health (McIntyre, Fralick), Toronto, Ont.; Leslie Dan Faculty of Pharmacy (McIntyre), University of Toronto; Li Ka Shing Knowledge Institute (Saha, Verma, Razak), St. Michael's Hospital, Toronto, Ont.; Department of Social and Behavioral Sciences (Saha), Harvard T.H. Chan School of Public Health, Boston, Mass.; Department of Medicine (Morris, Lapointe-Shaw, Weinerman, Fralick, Verma, Razak), University of Toronto; Department of Medicine (Morris), Mount Sinai Hospital and University Health Network; Department of Medicine (Lapointe-Shaw), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Weinerman), Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Agarwal); Department of Medicine (Agarwal), McMaster University, Hamilton, Ont
| | - Terence Tang
- Sinai Health (McIntyre, Fralick), Toronto, Ont.; Leslie Dan Faculty of Pharmacy (McIntyre), University of Toronto; Li Ka Shing Knowledge Institute (Saha, Verma, Razak), St. Michael's Hospital, Toronto, Ont.; Department of Social and Behavioral Sciences (Saha), Harvard T.H. Chan School of Public Health, Boston, Mass.; Department of Medicine (Morris, Lapointe-Shaw, Weinerman, Fralick, Verma, Razak), University of Toronto; Department of Medicine (Morris), Mount Sinai Hospital and University Health Network; Department of Medicine (Lapointe-Shaw), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Weinerman), Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Agarwal); Department of Medicine (Agarwal), McMaster University, Hamilton, Ont
| | - Adina Weinerman
- Sinai Health (McIntyre, Fralick), Toronto, Ont.; Leslie Dan Faculty of Pharmacy (McIntyre), University of Toronto; Li Ka Shing Knowledge Institute (Saha, Verma, Razak), St. Michael's Hospital, Toronto, Ont.; Department of Social and Behavioral Sciences (Saha), Harvard T.H. Chan School of Public Health, Boston, Mass.; Department of Medicine (Morris, Lapointe-Shaw, Weinerman, Fralick, Verma, Razak), University of Toronto; Department of Medicine (Morris), Mount Sinai Hospital and University Health Network; Department of Medicine (Lapointe-Shaw), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Weinerman), Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Agarwal); Department of Medicine (Agarwal), McMaster University, Hamilton, Ont
| | - Michael Fralick
- Sinai Health (McIntyre, Fralick), Toronto, Ont.; Leslie Dan Faculty of Pharmacy (McIntyre), University of Toronto; Li Ka Shing Knowledge Institute (Saha, Verma, Razak), St. Michael's Hospital, Toronto, Ont.; Department of Social and Behavioral Sciences (Saha), Harvard T.H. Chan School of Public Health, Boston, Mass.; Department of Medicine (Morris, Lapointe-Shaw, Weinerman, Fralick, Verma, Razak), University of Toronto; Department of Medicine (Morris), Mount Sinai Hospital and University Health Network; Department of Medicine (Lapointe-Shaw), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Weinerman), Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Agarwal); Department of Medicine (Agarwal), McMaster University, Hamilton, Ont
| | - Arnav Agarwal
- Sinai Health (McIntyre, Fralick), Toronto, Ont.; Leslie Dan Faculty of Pharmacy (McIntyre), University of Toronto; Li Ka Shing Knowledge Institute (Saha, Verma, Razak), St. Michael's Hospital, Toronto, Ont.; Department of Social and Behavioral Sciences (Saha), Harvard T.H. Chan School of Public Health, Boston, Mass.; Department of Medicine (Morris, Lapointe-Shaw, Weinerman, Fralick, Verma, Razak), University of Toronto; Department of Medicine (Morris), Mount Sinai Hospital and University Health Network; Department of Medicine (Lapointe-Shaw), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Weinerman), Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Agarwal); Department of Medicine (Agarwal), McMaster University, Hamilton, Ont
| | - Amol Verma
- Sinai Health (McIntyre, Fralick), Toronto, Ont.; Leslie Dan Faculty of Pharmacy (McIntyre), University of Toronto; Li Ka Shing Knowledge Institute (Saha, Verma, Razak), St. Michael's Hospital, Toronto, Ont.; Department of Social and Behavioral Sciences (Saha), Harvard T.H. Chan School of Public Health, Boston, Mass.; Department of Medicine (Morris, Lapointe-Shaw, Weinerman, Fralick, Verma, Razak), University of Toronto; Department of Medicine (Morris), Mount Sinai Hospital and University Health Network; Department of Medicine (Lapointe-Shaw), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Weinerman), Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Agarwal); Department of Medicine (Agarwal), McMaster University, Hamilton, Ont
| | - Fahad Razak
- Sinai Health (McIntyre, Fralick), Toronto, Ont.; Leslie Dan Faculty of Pharmacy (McIntyre), University of Toronto; Li Ka Shing Knowledge Institute (Saha, Verma, Razak), St. Michael's Hospital, Toronto, Ont.; Department of Social and Behavioral Sciences (Saha), Harvard T.H. Chan School of Public Health, Boston, Mass.; Department of Medicine (Morris, Lapointe-Shaw, Weinerman, Fralick, Verma, Razak), University of Toronto; Department of Medicine (Morris), Mount Sinai Hospital and University Health Network; Department of Medicine (Lapointe-Shaw), University Health Network, Toronto, Ont.; Trillium Health Partners (Tang), Mississauga, Ont.; Department of Medicine (Weinerman), Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Agarwal); Department of Medicine (Agarwal), McMaster University, Hamilton, Ont
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Grailey K, Lound A, Murray E, Brett SJ. The influence of personality on psychological safety, the presence of stress and chosen professional roles in the healthcare environment. PLoS One 2023; 18:e0286796. [PMID: 37276225 DOI: 10.1371/journal.pone.0286796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 05/23/2023] [Indexed: 06/07/2023] Open
Abstract
Healthcare teams are expected to deliver high quality and safe clinical care, a goal facilitated by an environment of psychological safety. We hypothesised that an individual's personality would influence psychological safety, perceived stressors in the clinical environment and confer a suitability for different professional roles. Staff members were recruited from the Emergency or Critical Care Departments of one National Health Service Trust. Qualitative interviews explored participants' experiences of personality, incorporating quantitative surveys to evaluate psychological safety and perceived stressors. The 16 Primary Factor Assessment provided a quantitative measure of personality. Participants demonstrated midrange scores for most personality traits, highlighting an ability to adapt to changing environments and requirements. There was a signal that different personality traits predominated between the two professional groups, and that certain traits were significantly associated with higher psychological safety and certain perceived stressors. Personality was described as having a strong influence on teamwork, the working environment and leadership ability. Our analysis highlights that personality can influence team dynamics and the suitability of individuals for certain clinical roles. Understanding the heterogeneity of personalities of team members and their likely responses to challenge may help leaders to support staff in times of challenge and improve team cohesiveness.
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Affiliation(s)
- Kate Grailey
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Adam Lound
- Patient Experience Research Centre, School of Public Health, Imperial College London, London, United Kingdom
| | - Eleanor Murray
- Said Business School, University of Oxford, Oxford, United Kingdom
| | - Stephen J Brett
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
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22
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Baghdadi JD, Goodman KE, Magder LS, Heil EL, Claeys K, Bork J, Harris AD. Clinical, contextual and hospital-level factors associated with escalation and de-escalation of empiric Gram-negative antibiotics among US inpatients. JAC Antimicrob Resist 2023; 5:dlad054. [PMID: 37193004 PMCID: PMC10182731 DOI: 10.1093/jacamr/dlad054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 04/19/2023] [Indexed: 05/18/2023] Open
Abstract
Background Empiric Gram-negative antibiotics are frequently changed in response to new information. To inform antibiotic stewardship, we sought to identify predictors of antibiotic changes using information knowable before microbiological test results. Methods We performed a retrospective cohort study. Survival-time models were used to evaluate clinical factors associated with antibiotic escalation and de-escalation (defined as an increase or decrease, respectively, in the spectrum or number of Gram-negative antibiotics within 5 days of initiation). Spectrum was categorized as narrow, broad, extended or protected. Tjur's D statistic was used to estimate the discriminatory power of groups of variables. Results In 2019, 2 751 969 patients received empiric Gram-negative antibiotics at 920 study hospitals. Antibiotic escalation occurred in 6.5%, and 49.2% underwent de-escalation; 8.8% were changed to an equivalent regimen. Escalation was more likely when empiric antibiotics were narrow-spectrum (HR 19.0 relative to protected; 95% CI: 17.9-20.1), broad-spectrum (HR 10.3; 95% CI: 9.78-10.9) or extended-spectrum (HR 3.49; 95% CI: 3.30-3.69). Patients with sepsis present on admission (HR 1.94; 95% CI: 1.91-1.96) and urinary tract infection present on admission (HR 1.36; 95% CI: 1.35-1.38) were more likely to undergo antibiotic escalation than patients without these syndromes. De-escalation was more likely with combination therapy (HR 2.62 per additional agent; 95% CI: 2.61-2.63) or narrow-spectrum empiric antibiotics (HR 1.67 relative to protected; 95% CI: 1.65-1.69). Choice of empiric regimen accounted for 51% and 74% of the explained variation in antibiotic escalation and de-escalation, respectively. Conclusions Empiric Gram-negative antibiotics are frequently de-escalated early in hospitalization, whereas escalation is infrequent. Changes are primarily driven by choice of empiric therapy and presence of infectious syndromes.
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Affiliation(s)
- Jonathan D Baghdadi
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Katherine E Goodman
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Laurence S Magder
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Emily L Heil
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Kimberly Claeys
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Jacqueline Bork
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Anthony D Harris
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
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İnat G, Sırıken B, Çiftci A, Erol İ, Başkan C, Yıldırım T. Molecular characterization of extended-spectrum β-lactamases-producing Enterobacteriaceae species in ground beef and chicken meat. Int J Food Microbiol 2023; 398:110228. [PMID: 37148785 DOI: 10.1016/j.ijfoodmicro.2023.110228] [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: 01/19/2023] [Revised: 04/18/2023] [Accepted: 04/24/2023] [Indexed: 05/08/2023]
Abstract
The objectives of this study were i) to characterize extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-E) using pheno- and genotyping methods, ii) to evaluate the antimicrobial resistance pattern against 10 antibiotics, and iii) to investigate class 1 integron (intI1) in 80 Enterobacteriaceae isolates obtained from chicken meat (n = 40; 47 isolates) and ground beef (n = 40; 33 isolates) samples. Through the study, we found that 55 (68.7 %) of 80 Enterobacteriaceae isolates were capable of β-lactamase activity, and 38 (47.5 %) of them were multi-drug-resistant (MDR). The ground meat-origin isolates are 1.2 times more likely to produce imipenem resistance compared to chicken-meat-origin isolates (z = 2.1, p < 0.05, OR = 1.42). ESBL-E was found in 18 (22.5 %) of the isolates, 16.3 % of chicken meat and 6.3 % of ground beef origin. The bla genes were detected in 14 isolates [bla-TEM (n = 10; 12.5 %); bla-SHV (n = 4; 5.0 %); bla-CTX-M (n = 0)], where the predominant species were Escherichia (E.) coli and Citrobacter braakii. The nine ESBL-E isolates were MDR. Twenty-eight (35.0 %) of 80 isolates were found to be resistant to at least one third-generation cephalosporin, and eight (28.6 %) of them were also ESBL-E. Eleven of 16 (48.5 %) carbapenem-resistant isolates were ESBL-E. The intI1 gene was found in 13 (16.3 %) isolates, five of which were ESBL-E, and four of which were MDR. Co-existing with bla-TEM and the intI1 isolate was ESBL-E. coli, which was resistant to nine antibiotics. In conclusion, chicken meat and ground beef may pose a potential risk of containing ESBL-E, and bla genes which could be spread to the entire food chain.
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Affiliation(s)
- Gökhan İnat
- Department of Food Hygiene and Technology, Faculty of Veterinary Medicine, Ondokuz Mayıs University, Samsun, Türkiye
| | - Belgin Sırıken
- Department of Aquatic Animal Diseases, Faculty of Veterinary Medicine, Ondokuz Mayıs University, Samsun, Türkiye.
| | - Alper Çiftci
- Department of Microbiology, Faculty of Veterinary Medicine, Ondokuz Mayıs University, Samsun, Türkiye
| | - İrfan Erol
- Faculty of Health Sciences, Lokman Hekim University, Ankara, Türkiye
| | - Ceren Başkan
- Department of Physical Therapy and Rehabilitation, Sabuncuoğlu Şerefeddin Health Services Vocational School, Amasya University, Amasya, Türkiye
| | - Tuba Yıldırım
- Department of Biology, Faculty of Arts and Sciences, Amasya University, Amasya, Türkiye
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Nampoothiri V, Mbamalu O, Surendran S, Bonaconsa C, Pennel T, Boutall A, Gopal K, Castro Sanchez E, Dhar P, Holmes A, Singh S, Mendelson M, Tarrant C, Charani E. The elephant in the room: Exploring the influence and participation of patients in infection-related care across surgical pathways in South Africa and India. Health Expect 2023; 26:892-904. [PMID: 36721315 PMCID: PMC10010088 DOI: 10.1111/hex.13715] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 01/05/2023] [Accepted: 01/17/2023] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVE The irrational use of antibiotics is a leading contributor to antibiotic resistance. Antibiotic stewardship (AS) interventions predominantly focus on prescribers. This study investigated the influence and participation of inpatients in infection-related care, including antibiotic decision-making, within and across two tertiary hospitals in South Africa (Cape Town) and India (Kerala). METHODS Through ethnographic enquiry of clinical practice in surgical pathways, including direct nonparticipant observation of clinical practices, healthcare worker (HCW), patient and carer interactions in surgical ward rounds and face-to-face interviews with participants (HCWs and patients), we sought to capture the implicit and explicit influence that patients and carers have in infection-related care. Field notes and interview transcripts were thematically coded, aided by NVivo 12® Pro software. RESULTS Whilst observational data revealed the nuanced roles that patients/carers play in antibiotic decision-making, HCWs did not recognize these roles. Patients and carers, though invested in patient care, are not routinely involved, nor are they aware of the opportunities for engagement in infection-related decision-making. Patients associated clinical improvement with antibiotic use and did not consider hospitalization to be associated with infection acquisition or transmission, highlighting a lack of understanding of the threat of infection and antibiotic resistance. Patients' economic and cultural positionalities may influence their infection-related behaviours. In the study site in India, cultural norms mean that carers play widespread but unrecognized roles in inpatient care, participating in infection prevention activities. CONCLUSION For patients to have a valuable role in AS and make informed decisions regarding their infection-related care, a mutual understanding of their role in this process among HCWs and patients is crucial. The observed differences between the two study sites indicate the critical need for understanding and addressing the contextual drivers that impact effective patient-centred healthcare delivery. PATIENT OR PUBLIC CONTRIBUTION Ethnographic observations and interviews conducted in this study involved patients as participants. Patients were recruited for interviews after obtaining signed informed consent forms. Patients' identities were completely anonymized when presenting the study findings.
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Affiliation(s)
- Vrinda Nampoothiri
- Department of Infection Control and Epidemiology, Amrita Institute of Medical Science, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Oluchi Mbamalu
- Department of Medicine, Division of Infectious Diseases & HIV Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Surya Surendran
- Department of Infection Control and Epidemiology, Amrita Institute of Medical Science, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India.,Division of Health System and Equity, The George Institute for Global Health, New Delhi, India
| | - Candice Bonaconsa
- Department of Medicine, Division of Infectious Diseases & HIV Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Timothy Pennel
- Division of Cardiothoracic Surgery, University of Cape Town, Cape Town, South Africa
| | - Adam Boutall
- Colorectal Unit, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Kirun Gopal
- Department of Cardiovascular and Thoracic Surgery, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Enrique Castro Sanchez
- School of Health Sciences, Division of Nursing, University of London, London, UK.,National Institute for Health and Care Research, Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance, Imperial College London, London, UK
| | - Puneet Dhar
- All India Institute of Medical Sciences, Rishikesh, India
| | - Alison Holmes
- National Institute for Health and Care Research, Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance, Imperial College London, London, UK
| | - Sanjeev Singh
- Department of Infection Control and Epidemiology, Amrita Institute of Medical Science, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Marc Mendelson
- Department of Medicine, Division of Infectious Diseases & HIV Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Carolyn Tarrant
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Esmita Charani
- Department of Infection Control and Epidemiology, Amrita Institute of Medical Science, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India.,Department of Medicine, Division of Infectious Diseases & HIV Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa.,National Institute for Health and Care Research, Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance, Imperial College London, London, UK.,Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
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Jung N, Tometten L, Draenert R. Choosing Wisely internationally - helpful recommendations for antimicrobial stewardship! Infection 2023; 51:567-581. [PMID: 36840828 DOI: 10.1007/s15010-023-02005-y] [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: 02/05/2023] [Accepted: 02/14/2023] [Indexed: 02/26/2023]
Abstract
PURPOSE Antimicrobial resistance poses a major threat to human health globally and antibiotic overuse is a main driver of resistance. Antimicrobial stewardship (AMS) was developed to improve the rationale use of antibiotics. The Choosing Wisely campaign was initiated to ameliorate medical practice through avoidance of unnecessary diagnostic and therapeutic procedures. Our objective was to give an overview on the Choosing Wisely recommendations related to AMS practices from a selection of different countries in order to define future needs. METHODS We evaluated the seven countries already analyzed for Choosing Wisely recommendations related to topics of infectious medicine before. Finally, we included five of the former countries (Australia/New Zealand, Canada, Italy, Switzerland, and USA) and Germany with easily accessible recommendations and selected those related to six categories of AMS as following: diagnostics, indication, choice of antiinfective drugs, dosing, application and duration of therapy. RESULTS In total, 213 recommendations could be extracted related to AMS for the six countries and were matched to the chosen categories. Interestingly, no recommendations were found for the category "dosing." Topics related to indication and diagnostics were most frequently found with 85 and 78 recommendations, respectively. Perioperative prophylaxis was a frequently addressed issue - both related to application, indication and duration. Avoiding antibiotic treatment of asymptomatic bacteriuria and upper respiratory tract infections were central topics of all countries. CONCLUSION AMS is an important strategy to fight increasing resistance and is frequently addressed by Choosing Wisely recommendations of different countries. Similar issues are considered important in the selected countries.
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Affiliation(s)
- Norma Jung
- Department I of Internal Medicine, Division of Infectious Diseases, University of Cologne, Faculty of Medicine, University Clinics, Cologne, Germany.
| | - Lukas Tometten
- Department I of Internal Medicine, Division of Infectious Diseases, University of Cologne, Faculty of Medicine, University Clinics, Cologne, Germany
| | - Rika Draenert
- Interdisciplinary Antibiotic Stewardship Team, LMU Klinikum, Munich, Germany
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Patient expectations do matter - Experimental evidence on antibiotic prescribing decisions among hospital-based physicians. Health Policy 2023; 128:11-17. [PMID: 36450627 DOI: 10.1016/j.healthpol.2022.11.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 10/28/2022] [Accepted: 11/17/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND The global public health crisis of antibiotic resistance is being driven in part by over prescription of antibiotics. We aimed to assess the relative weight of patient expectations, clinical uncertainty, and past behaviour on hospital-based physicians' antibiotic prescribing decisions. METHODS A discrete choice experiment was administered among hospital-based physicians in Tuscany, Italy. Respondents were asked to choose in which of two clinical scenarios they would be more likely to prescribe antibiotics, with the two cases differing in levels of clinical uncertainty, patient expectations, and the physician's past behaviour. We fitted a conditional logistic regression. RESULTS Respondents included 1,436 hospital-based physicians. Results show that the odds of prescribing antibiotics decrease when a patient requests it (OR=0.80, 95%CI [0.72,0.89]) and increase when the physician has prescribed antibiotics to a patient under similar circumstances previously (OR=1.15, 95%CI [1.03,1.27]). We found no significant effect of clinical uncertainty on the odds of prescribing antibiotics (OR=0.96, 95%CI [0.87, 1.07]). CONCLUSIONS We show that patient expectation has a significant negative association with antibiotic prescribing among hospital-based physicians. Our findings speak to the importance of cultural context in shaping the physician's disposition when confronted with patient expectations. We suggest shared decision-making to improve prudent prescribing without compromising on patient satisfaction.
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Huang Z, Yao G, Zhang C, Zhou X, Zou G, Zhuo C. Evaluation and Analysis of the Rationality of Clinical Use of Carbapenems in Surgical Departments of a Tertiary Hospital in Southwest China. Infect Drug Resist 2023; 16:2259-2269. [PMID: 37090035 PMCID: PMC10120811 DOI: 10.2147/idr.s403787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 03/22/2023] [Indexed: 04/25/2023] Open
Abstract
Purpose With the increasing frequency and intensity of carbapenem consumption, carbapenem-resistant organisms (CRO) have become a focus of anti-infection research. This study aimed to evaluate the rationality of the clinical use of carbapenems among inpatients in the surgical departments of a tertiary hospital in southwest China. Patients and methods A point-score system was established for evaluation based on the clinical practices in surgical departments and selected carbapenem prescriptions from June 2020 to June 2021 for hepatobiliary surgery, gastrointestinal surgery, and neurosurgery in the study hospital. Prescriptions with a total score ≥ 270 were defined as rational. Descriptive statistics were used to describe the characteristics and rationality of the prescriptions. The chi-square test, Mann-Whitney U-test, and Kruskal-Wallis H-test were used to compare characteristics between rational and irrational prescriptions. Linear regression analysis was used to determine the factors affecting the rationality of carbapenem prescriptions. Results According to 192 carbapenem prescription records, the median age of patients was 62 years [IQR, 48.0-73.0], and 20% of patients had abdominal infections, 10% had lung infections, 14% had intracranial infections, and 3% had urinary tract infections. 56% of carbapenem prescriptions were irrational. Compared with rational carbapenem prescriptions, irrational prescriptions had a higher proportion of those with inappropriate indications (49% vs 0%, p < 0.05), incorrect variety selection (15% vs 0%, p<0.05), and unreasonable assessment of etiology and efficacy (46% vs 8%, p < 0.05). Linear regression analysis suggested that the diagnosis of cholecystitis (standardized regression coefficient=0.183, p<0.05) and replaced medication (standardized regression coefficient = 0.154, p<0.05) influenced the rationality of carbapenem prescriptions. Conclusion Our study shows that the irrational use of carbapenems deserves attention, especially in surgical departments. Interventions for carbapenem use that are based on evaluation criteria should be developed to reduce the emergence and spread of carbapenem-resistant bacteria.
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Affiliation(s)
- Zhongyue Huang
- Institute of Medical Information/Medical Library, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People’s Republic of China
| | - Gaoqiong Yao
- Department of Pharmacy, First Affiliated Hospital of Chongqing Medical University, Chongqing, People’s Republic of China
| | - Chengzhi Zhang
- Department of Pharmacy, First Affiliated Hospital of Chongqing Medical University, Chongqing, People’s Republic of China
| | - Xin Zhou
- Department of Pharmacy, First Affiliated Hospital of Chongqing Medical University, Chongqing, People’s Republic of China
| | - Guanyang Zou
- School of Public Health and Management, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong Province, People’s Republic of China
- Correspondence: Guanyang Zou, No. 232, Waihuan East Road, Panyu District, Guangzhou, Guangdong Province, 510006, People’s Republic of China, Email
| | - Chao Zhuo
- State Key Laboratory of Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong Province, People’s Republic of China
- Chao Zhuo, 195 Dongfeng West Road, Yuexiu District, Guangzhou, Guangdong Province, 510030, People’s Republic of China, Email
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Strahilevitz J, Oreg S, Nir Paz R, Sagiv L. Nurses' and Physicians' Responses to a New Active Antimicrobial Stewardship Program: A Two-Phase Study of Responses and Their Underlying Perceptions and Values. Int J Health Policy Manag 2022; 11:2982-2989. [PMID: 35596273 PMCID: PMC10105176 DOI: 10.34172/ijhpm.2022.6557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 05/08/2022] [Indexed: 11/09/2022] Open
Abstract
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.
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Affiliation(s)
- Jacob Strahilevitz
- Department of Clinical Microbiology and Infectious Diseases, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
- Faculty of Medicine, The Hebrew University, Jerusalem, Israel
| | - Shaul Oreg
- School of Business Administration, The Hebrew University, Jerusalem, Israel
| | - Ran Nir Paz
- Department of Clinical Microbiology and Infectious Diseases, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
- Faculty of Medicine, The Hebrew University, Jerusalem, Israel
| | - Lilach Sagiv
- School of Business Administration, The Hebrew University, Jerusalem, Israel
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Ahuja S, Singh S, Charani E, Surendran S, Nampoothiri V, Edathadathil F, George A, Leather A, Tarrant C, Holmes A, Sevdalis N, Birgand G. An evaluation of the implementation of interventions to reduce postoperative infections and optimise antibiotic use across the surgical pathway in India: a mixed-methods exploratory study protocol. Pilot Feasibility Stud 2022; 8:237. [PMID: 36335367 PMCID: PMC9636821 DOI: 10.1186/s40814-022-01192-z] [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: 01/17/2022] [Accepted: 10/17/2022] [Indexed: 11/07/2022] Open
Abstract
INTRODUCTION Postoperative infections represent a significant burden of disease, demanding antibiotic prescriptions, and are contributing to antimicrobial resistance. The burden of infection as a surgical complication is greater in low- and middle-income countries (LMICs). We report the protocol of a pilot study for the co-design, implementation and evaluation of two infection prevention and control (IPC) and antimicrobial stewardship (AMS) interventions across the surgical pathway in a teaching hospital in India. METHODS AND ANALYSIS The two interventions developed following in-depth qualitative enquiry are (i) surveillance and feedback of postoperative infections to optimise the use of antibiotics in two surgical departments (gastrointestinal and cardiovascular and thoracic surgery) and (ii) raising awareness amongst patients, carers and members of public about IPC and AMS. We will conduct a prospective study, formatively evaluating the implementation process of delivering the two co-designed interventions using implementation science frameworks. The study will systematically assess the context of intervention delivery, so that implementation support for the interventions may be adapted to the needs of stakeholders throughout the study. Analysis of implementation logs and interviews with stakeholders upon completion of the implementation period, will offer insights into the perceived acceptability, appropriateness, feasibility and sustainability of the interventions and their implementation support. Implementation costs will be captured descriptively. Feasibility of clinical data collection to investigate effectiveness of interventions will also be assessed for a future larger study. Thematic framework analysis and descriptive statistics will be used to report the qualitative and quantitative data, respectively. STRENGTHS AND LIMITATIONS OF THIS STUDY • The paired interventions have been co-designed from their inception with involvement of stakeholders at different stages in the surgical pathway. • Simultaneous evaluation of implementation and clinical outcomes will inform the development of a future larger study to enable/assess the scalability of interventions • The study offers a novel combination of implementation theory-informed, stakeholder-driven and clinically relevant evaluation, carried out in the context of a middle-income country hospital. • The project may not be applicable to every low-resource setting and surgical context due to differences in healthcare systems and cultures. However, the application of implementation science concepts may facilitate transferability and adaptation to other settings.
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Affiliation(s)
- Shalini Ahuja
- grid.13097.3c0000 0001 2322 6764Centre for Implementation Science, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK ,grid.13097.3c0000 0001 2322 6764Florence Nightingale Faculty of Nursing and Midwifery, King’s College London, London, UK
| | - Sanjeev Singh
- grid.427788.60000 0004 1766 1016Department of Infection Control and Epidemiology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham University, Kochi, Kerala India
| | - Esmita Charani
- grid.7445.20000 0001 2113 8111Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Department of Medicine, Imperial College London, London, UK ,grid.7836.a0000 0004 1937 1151Division of Infectious Diseases & HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Surya Surendran
- grid.464831.c0000 0004 8496 8261Health Systems and Equity, The George Institute for Global Health, New Delhi, India
| | - Vrinda Nampoothiri
- grid.427788.60000 0004 1766 1016Department of Infection Control and Epidemiology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham University, Kochi, Kerala India
| | - Fabia Edathadathil
- grid.427788.60000 0004 1766 1016Amrita Institute of Medical Sciences, Kochi, India
| | - Anu George
- grid.427788.60000 0004 1766 1016Department of Infection Control and Epidemiology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham University, Kochi, Kerala India
| | - Andrew Leather
- grid.13097.3c0000 0001 2322 6764King’s Centre for Global Health and Health Partnerships, School of Life Course and Population Sciences, King’s College London, London, UK
| | - Carolyn Tarrant
- grid.9918.90000 0004 1936 8411Department of Health Sciences, University of Leicester, Leicester, UK
| | - Alison Holmes
- grid.7445.20000 0001 2113 8111Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Department of Medicine, Imperial College London, London, UK
| | - Nick Sevdalis
- grid.13097.3c0000 0001 2322 6764Centre for Implementation Science, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Gabriel Birgand
- grid.7445.20000 0001 2113 8111Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Department of Medicine, Imperial College London, London, UK
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Vallicelli C, Santandrea G, Sartelli M, Coccolini F, Ansaloni L, Agnoletti V, Bravi F, Catena F. Sepsis Team Organizational Model to Decrease Mortality for Intra-Abdominal Infections: Is Antibiotic Stewardship Enough? Antibiotics (Basel) 2022; 11:1460. [PMID: 36358115 PMCID: PMC9687019 DOI: 10.3390/antibiotics11111460] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 10/17/2022] [Accepted: 10/18/2022] [Indexed: 09/22/2023] Open
Abstract
Introduction. Sepsis is an overwhelming reaction to infection with significant morbidity, requiring urgent interventions in order to improve outcomes. The 2016 Sepsis-3 guidelines modified the previous definitions of sepsis and septic shock, and proposed some specific diagnostic and therapeutic measures to define the use of fluid resuscitation and antibiotics. However, some open issues still exist. Methods. A literature research was performed on PubMed and Cochrane using the terms "sepsis" AND "intra-abdominal infections" AND ("antibiotic therapy" OR "antibiotic treatment"). The inclusion criteria were management of intra-abdominal infection (IAI) and effects of antibiotic stewardships programs (ASP) on the outcome of the patients. Discussion. Sepsis-3 definitions represent an added value in the understanding of sepsis mechanisms and in the management of the disease. However, some questions are still open, such as the need for an early identification of sepsis. Sepsis management in the context of IAI is particularly challenging and a prompt diagnosis is essential in order to perform a quick treatment (source control and antibiotic treatment). Antibiotic empirical therapy should be based on the kind of infection (community or hospital acquired), local resistances, and patient's characteristic and comorbidities, and should be adjusted or de-escalated as soon as microbiological information is available. Antibiotic Stewardship Programs (ASP) have demonstrated to improve antimicrobial utilization with reduction of infections, emergence of multi-drug resistant bacteria, and costs. Surgeons should not be alone in the management of IAI but ideally inserted in a sepsis team together with anaesthesiologists, medical physicians, pharmacists, and infectious diseases specialists, meeting periodically to reassess the response to the treatment. Conclusion. The cornerstones of sepsis management are accurate diagnosis, early resuscitation, effective source control, and timely initiation of appropriate antimicrobial therapy. Current evidence shows that optimizing antibiotic use across surgical specialities is imperative to improve outcomes. Ideally every hospital and every emergency surgery department should aim to provide a sepsis team in order to manage IAI.
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Affiliation(s)
- Carlo Vallicelli
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, 47521 Cesena, Italy
| | - Giorgia Santandrea
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, 47521 Cesena, Italy
| | | | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, 56124 Pisa, Italy
| | - Luca Ansaloni
- Department of General and Emergency Surgery, Policlinico San Matteo, 27100 Pavia, Italy
| | - Vanni Agnoletti
- Anesthesia, Intensive Care and Trauma Department, Bufalini Hospital, 47521 Cesena, Italy
| | - Francesca Bravi
- Healthcare Administration, Santa Maria delle Croci Hospital, 48121 Ravenna, Italy
| | - Fausto Catena
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, 47521 Cesena, Italy
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Membrilla-Fernández E, Gómez-Zorrilla S, González-Castillo AM, Pelegrina-Manzano A, Guzmán-Ahumada J, Prim N, Echeverria-Esnal D, Grau-Cerrato S, Horcajada-Gallego JP, Badía JM, Sancho-Insenser JJ. Scientific evidence of the duration of antibiotic treatment in intra-abdominal infections with surgical focus control. Cir Esp 2022; 100:608-613. [PMID: 35760316 DOI: 10.1016/j.cireng.2022.06.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 01/22/2022] [Indexed: 06/15/2023]
Abstract
A non-systematic review of the published scientific evidence has been carried out on the duration of empirical antibiotic treatment in surgical intra-abdominal infections (IIA) with effective focus control. Given the progressive increase in antibiotic resistance, it is urgent to have strategies to reduce the pressure on the microbiota. The American guidelines made by Mazuski et al. of 20171, as the central axis in the recommendations of the duration of empirical antibiotic treatment in intra-abdominal infections with control of the focus and a bibliographic search of all the articles that contained the keywords in Pubmed and Google Scholar is added. 21 articles referring to the duration of empirical antibiotic treatment in intra-abdominal infection with control of the focus are collected. With the American guidelines and these articles, a proposal is prepared for the duration of empirical antibiotic treatment in patients without risk factors between 24 and 72 h. And in those who present risk factors, it should be individualized with active monitoring every 24 h of fever, paralytic ileus and leukocytosis (FIL), before an early detection of complications or the need for changes in antibiotic treatment. Short treatments are just as effective as those of longer durations and are associated with fewer adverse effects, therefore, daily adjusting and reassessing the duration of empirical antibiotic treatment is essential for better practice.
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Affiliation(s)
| | | | | | | | - Juan Guzmán-Ahumada
- Servicio de Cirugía General y Aparato Digestivo, Hospital del Mar de Barcelona, Spain
| | - Nuria Prim
- Servicio de Microbiología, Laboratorio de Referencia de Cataluña, Spain
| | | | | | | | - Josep María Badía
- Servicio de Cirugía General y Aparato Digestivo, Hospital de Granollers, Universitat Internacional de Catalunya, Spain
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Tailoring Antimicrobial Stewardship (AMS) Interventions to the Cultural Context: An Investigation of AMS Programs Operating in Northern Italian Acute-Care Hospitals. Antibiotics (Basel) 2022; 11:antibiotics11091257. [PMID: 36140036 PMCID: PMC9495251 DOI: 10.3390/antibiotics11091257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 09/06/2022] [Accepted: 09/14/2022] [Indexed: 11/16/2022] Open
Abstract
Antibiotic misuse and overuse are important contributors to the development of antimicrobial resistance (AMR). Antimicrobial stewardship (AMS) programs are coordinated sets of actions aiming to promote appropriate antibiotic use, improving patient outcomes whilst reducing AMR. Two main organizational models for AMS programs have been described: restrictive strategies (RS) vs. enabling strategies (ES). Evaluating and understanding social and cultural influences on antibiotic decision-making are critical for the development of successful and sustainable context-specific AMS programs. Characteristics and surrogate outcomes of AMS programs operating in acute-care hospitals of Piedmont in north-western Italy were investigated. The aim of this study was assessing whether RS vs. ES operating in our context were associated with different outcomes in terms of total antimicrobial usage and percentage of methicillin-resistant Staphylococcus aureus (MRSA) and carbapenem-resistant enterobacteria (CRE) over invasive isolates. In total, 24 AMS programs were assessed. ES were more frequently chosen compared to RS, with the latter being implemented only in broader AMS programs involving enabling components (combined strategy, CS). This study found no difference in evaluated outcomes among hospitals implementing ES vs. CS, suggesting both approaches could be equally valid in our context.
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Surendran S, Castro-Sánchez E, Nampoothiri V, Joseph S, Singh S, Tarrant C, Holmes A, Charani E. Indispensable yet invisible: A qualitative study of the roles of carers in infection prevention in a South Indian hospital. Int J Infect Dis 2022; 123:84-91. [PMID: 35988864 DOI: 10.1016/j.ijid.2022.08.011] [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: 01/20/2022] [Revised: 07/21/2022] [Accepted: 08/15/2022] [Indexed: 10/15/2022] Open
Abstract
OBJECTIVES We investigated the roles of patient carers in infection-related care on surgical wards in a South Indian hospital from the perspective of healthcare workers (HCWs), patients, and their carers. METHODS Ethnographic study included ward-round observations (138 hours) and face-to-face interviews (44 HCWs, 6 patients/carers). Data (field notes, interview transcripts) were coded in NVivo 12 and thematically analyzed. Data collection and analysis were iterative, recursive, and continued until thematic saturation. RESULTS Carers have important, unrecognized roles. At the study site, institutional expectations are formalized in policies, demanding a carer to always accompany in-patients. Such intense presence embeds families in the patient care environment, as demonstrated by their high engagement in direct personal (bathing patients) and clinical care (wound care). Carers actively participate in discussions on patient progress with HCWs, including therapeutic options. There is a misalignment between how carers are positioned by the organization (through policy mandates, institutional practices, and HCWs expectations), and the role that they play in practice, resulting in their role, though indispensable, remaining unrecognized. CONCLUSION Current models of patient and carer involvement in infection prevention and control are poorly aligned with sociocultural and contextual aspects of care. Culture-sensitive infection prevention and control policies which embrace the roles that carers play are urgently needed.
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Affiliation(s)
- Surya Surendran
- Department of Infection Control and Epidemiology, Amrita Institute of Medical Sciences, Kochi, India; Health System and Equity, The George Institute for Global Health, New Delhi, India
| | - Enrique Castro-Sánchez
- Department of Medicine, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, United Kingdom; School of Health Sciences, University of West London, London, United Kingdom
| | - Vrinda Nampoothiri
- Department of Infection Control and Epidemiology, Amrita Institute of Medical Sciences, Kochi, India
| | - Shiny Joseph
- Department of Gastrointestinal Surgery, Amrita Institute of Medical Sciences, Kochi, India
| | - Sanjeev Singh
- Department of Infection Control and Epidemiology, Amrita Institute of Medical Sciences, Kochi, India
| | - Carolyn Tarrant
- Department of Health Sciences, University of Leicester, Leicester, United Kingdom
| | - Alison Holmes
- Department of Medicine, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, United Kingdom
| | - Esmita Charani
- Department of Infection Control and Epidemiology, Amrita Institute of Medical Sciences, Kochi, India; Department of Medicine, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, United Kingdom; Centre for Excellence in Infectious Diseases Research, University of Liverpool, Liverpool, United Kingdom; Division of Infectious Diseases & HIV Medicine, Department of Medicine, University of Cape Town, South Africa.
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Feasibility of antimicrobial stewardship ward rounds on surgical wards led by a junior pharmacist. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2022. [DOI: 10.1002/jppr.1822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Tipping the balance: A systematic review and meta-ethnography to unfold the complexity of surgical antimicrobial prescribing behavior in hospital settings. PLoS One 2022; 17:e0271454. [PMID: 35857810 PMCID: PMC9299309 DOI: 10.1371/journal.pone.0271454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 07/01/2022] [Indexed: 11/19/2022] Open
Abstract
Surgical specialties account for a high proportion of antimicrobial use in hospitals, and misuse has been widely reported resulting in unnecessary patient harm and antimicrobial resistance. We aimed to synthesize qualitative studies on surgical antimicrobial prescribing behavior, in hospital settings, to explain how and why contextual factors act and interact to influence practice. Stakeholder engagement was integrated throughout to ensure consideration of varying interpretive repertoires and that the findings were clinically meaningful. The meta-ethnography followed the seven phases outlined by Noblit and Hare. Eight databases were systematically searched without date restrictions. Supplementary searches were performed including forwards and backwards citation chasing and contacting first authors of included papers to highlight further work. Following screening, 14 papers were included in the meta-ethnography. Repeated reading of this work enabled identification of 48 concepts and subsequently eight overarching concepts: hierarchy; fear drives action; deprioritized; convention trumps evidence; complex judgments; discontinuity of care; team dynamics; and practice environment. The overarching concepts interacted to varying degrees but there was no consensus among stakeholders regarding an order of importance. Further abstraction of the overarching concepts led to the development of a conceptual model and a line-of-argument synthesis, which posits that social and structural mediators influence individual complex antimicrobial judgements and currently skew practice towards increased and unnecessary antimicrobial use. Crucially, our model provides insights into how we might ‘tip the balance’ towards more evidence-based antimicrobial use. Currently, healthcare workers deploy antimicrobials across the surgical pathway as a safety net to allay fears, reduce uncertainty and risk, and to mitigate against personal blame. Our synthesis indicates that prescribing is unlikely to change until the social and structural mediators driving practice are addressed. Furthermore, it suggests that research specifically exploring the context for effective and sustainable quality improvement stewardship initiatives in surgery is now urgent.
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Limato R, Nelwan EJ, Mudia M, Alamanda M, Manurung ER, Mauleti IY, Mayasari M, Firmansyah I, Djaafar R, Vu HTL, van Doorn HR, Broom A, Hamers RL. Perceptions, views and practices regarding antibiotic prescribing and stewardship among hospital physicians in Jakarta, Indonesia: a questionnaire-based survey. BMJ Open 2022; 12:e054768. [PMID: 35589350 PMCID: PMC9121411 DOI: 10.1136/bmjopen-2021-054768] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 02/23/2022] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Antibiotic overuse is one of the main drivers of antimicrobial resistance (AMR), especially in low-income and middle-income countries. This study aimed to understand the perceptions and views towards AMR, antibiotic prescribing practice and antimicrobial stewardship (AMS) among hospital physicians in Jakarta, Indonesia. DESIGN Cross-sectional, self-administered questionnaire-based survey, with descriptive statistics, exploratory factor analysis (EFA) to identify distinct underlying constructs in the dataset, and multivariable linear regression of factor scores to analyse physician subgroups. SETTING Six public and private acute-care hospitals in Jakarta in 2019. PARTICIPANTS 1007 of 1896 (53.1% response rate) antibiotic prescribing physicians. RESULTS Physicians acknowledged the significance of AMR and contributing factors, rational antibiotic prescribing, and purpose and usefulness of AMS. However, this conflicted with reported suboptimal local hospital practices, such as room cleaning, hand hygiene and staff education, and views regarding antibiotic decision making. These included insufficiently applying AMS principles and utilising microbiology, lack of confidence in prescribing decisions and defensive prescribing due to pervasive diagnostic uncertainty, fear of patient deterioration or because patients insisted. EFA identified six latent factors (overall Crohnbach's α=0.85): awareness of AMS activities; awareness of AMS purpose; views regarding rational antibiotic prescribing; confidence in antibiotic prescribing decisions; perception of AMR as a significant problem; and immediate actions to contain AMR. Factor scores differed across hospitals, departments, work experience and medical hierarchy. CONCLUSIONS AMS implementation in Indonesian hospitals is challenged by institutional, contextual and diagnostic vulnerabilities, resulting in externalising AMR instead of recognising it as a local problem. Appropriate recognition of the contextual determinants of antibiotic prescribing decision making will be critical to change physicians' attitudes and develop context-specific AMS interventions.
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Affiliation(s)
- Ralalicia Limato
- Eijkman-Oxford Clinical Research Unit, Jakarta, Indonesia
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Erni Juwita Nelwan
- Department of Internal Medicine, Division of Infectious Diseases, Cipto Mangunkusumo National Hospital, Jakarta, Indonesia
- Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | | | - Monik Alamanda
- Eijkman-Oxford Clinical Research Unit, Jakarta, Indonesia
| | | | | | | | - Iman Firmansyah
- Prof. Dr. Sulianti Saroso Infectious Disease Hospital, Jakarta, Indonesia
| | - Roswin Djaafar
- Metropolitan Medical Centre Hospital, Jakarta, Indonesia
| | | | - H Rogier van Doorn
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- Oxford University Clinical Research Unit, Hanoi, Viet Nam
| | - Alex Broom
- Sydney Centre for Healthy Societies, School of Social and Political Sciences, The University of Sydney, Sydney, New South Wales, Australia
| | - Raph L Hamers
- Eijkman-Oxford Clinical Research Unit, Jakarta, Indonesia
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
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Kuti MA, Bamidele OT, Udeh CT, Eseile BJ, Ogundeji OA. Appropriate use of plasma glucose tests for diagnosis of diabetes mellitus in Ibadan, Nigeria. Afr J Lab Med 2022; 11:1433. [PMID: 35547334 PMCID: PMC9082232 DOI: 10.4102/ajlm.v11i1.1433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 02/07/2022] [Indexed: 01/09/2023] Open
Abstract
Background: Diabetes mellitus is a growing epidemic in Africa. Its diagnosis relies exclusively on laboratory evidence, which differs based on clinical circumstances.Objective: The study described the appropriateness of plasma glucose test requests per the American Diabetes Association criteria.Methods: We reviewed the plasma glucose test requests received by the chemical pathology laboratory of the University College Hospital, Ibadan, Nigeria between June 2018 and November 2018. The American Diabetes Association diabetes diagnostic criteria were used to define the appropriateness of test requests and determine the potential for ill-informed clinical decisions.Results: Four hundred and twenty-three requisition forms were included, with the majority from the medical wards/clinics (72.3%); the most frequent reason for a plasma glucose test was systemic hypertension (28.6%). Fasting plasma glucose was most requested (254; 60.0%). One hundred and sixteen (27.4%) requests were potentially inappropriate, with the 2-h postprandial plasma glucose (2hPPG) test requests (83; 71.6%) being the most inappropriate. The difference in the proportion of inappropriate requests was not statistically significantly between medical or surgical wards/clinics (Odds ratio 1.131, 95% confidence interval 0.709–1.803, p = 0.605). Inappropriate requests in six cases may have triggered inappropriate action.Conclusion: A third of the glucose tests requested for querying diabetes mellitus may have been inappropriate. Results of such testing may trigger inappropriate clinical action. To improve the quality of care and for economic reasons, laboratories should have programmes to improve the appropriate use of their services.
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Affiliation(s)
- Modupe A Kuti
- Department of Chemical Pathology, Faculty of Basic Medical Sciences, College of Medicine, University of Ibadan, Ibadan, Nigeria
- Department of Chemical Pathology, University College Hospital, Ibadan, Nigeria
| | - Olabisi T Bamidele
- Department of Chemical Pathology, University College Hospital, Ibadan, Nigeria
| | - Chioma T Udeh
- Department of Chemical Pathology, University College Hospital, Ibadan, Nigeria
| | - Bola J Eseile
- Department of Chemical Pathology, University College Hospital, Ibadan, Nigeria
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Morgan JE, Phillips B. PAnTher Cub: procalcitonin-guided antibiotic therapy for febrile neutropenia in children and young people with cancer - a single-arm pilot study. BMJ Paediatr Open 2022; 6:10.1136/bmjpo-2021-001339. [PMID: 36053620 PMCID: PMC8928328 DOI: 10.1136/bmjpo-2021-001339] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 01/28/2022] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Febrile neutropenia (FN) is a common complication of cancer treatment in children and young people, and many episodes are over-treated. Procalcitonin, may be an appropriate tool to guide the stopping of antibiotics in those at low risk of serious bacterial infection. Supportive care trials in this population have proven to be difficult to undertake. This single-arm pilot study aimed to evaluate whether a study using a procalcitonin-guided stopping-rule for antibiotics in paediatric FN is possible. METHODS Daily procalcitonin levels were performed during episodes of FN and clear guidance given for antibiotic discontinuation. Episode data and quantitative feasibility data were collected alongside interviews with professionals and ethnographic observations. Analysis was descriptive. RESULTS Of 32 patients and families approached, 28 patients consented, and 13 had febrile neutropenia. In total, 16 episodes were included in the study. All relevant FN episodes had data captured, with adequate data collection. There were no significant safety events. In 4/8 (50%) of episodes without clear microbiologically documented or clinical infection, antibiotics were reduced in duration or in spectrum. Interviews with professionals revealed the importance of the research, the value of key individuals in the study team, particular challenges of this protocol and suggestions for study improvements. CONCLUSIONS Studies to evaluate procalcitonin-guided approaches to stopping antibiotics in paediatric FN are possible.
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Affiliation(s)
- Jessica Elizabeth Morgan
- Department of Paediatric Haematology and Oncology, Leeds Children's Hospital, Leeds, UK .,Centre for Reviews and Dissemination, University of York, York, UK
| | - Bob Phillips
- Department of Paediatric Haematology and Oncology, Leeds Children's Hospital, Leeds, UK.,Centre for Reviews and Dissemination, University of York, York, UK
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Hueth KD, Prinzi AM, Timbrook TT. Diagnostic Stewardship as a Team Sport: Interdisciplinary Perspectives on Improved Implementation of Interventions and Effect Measurement. Antibiotics (Basel) 2022; 11:antibiotics11020250. [PMID: 35203852 PMCID: PMC8868553 DOI: 10.3390/antibiotics11020250] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 02/03/2022] [Accepted: 02/11/2022] [Indexed: 02/06/2023] Open
Abstract
Diagnostic stewardship aims to deliver the right test to the right patient at the right time and is optimally combined with antimicrobial stewardship to allow for the right interpretation to translate into the right antimicrobial at the right time. Laboratorians, physicians, pharmacists, and other healthcare providers have an opportunity to improve the effectiveness of diagnostics through collaborative activities around pre-analytical and post-analytical periods of diagnostic testing. Additionally, special considerations should be given to measuring the effectiveness of diagnostics over time. Herein, we perform a narrative review of the literature on these potential optimization opportunities and the temporal factors that can yield changes in diagnostic effectiveness. Our objective is to inform on these considerations to ensure enhanced value through improved implementation and measurement of effectiveness for local stakeholder metrics and/or clinical outcomes research.
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Affiliation(s)
- Kyle D. Hueth
- BioMérieux, Salt Lake City, UT 84104, USA; (K.D.H.); (A.M.P.)
| | | | - Tristan T. Timbrook
- BioMérieux, Salt Lake City, UT 84104, USA; (K.D.H.); (A.M.P.)
- College of Pharmacy, University of Utah, Salt Lake City, UT 84112, USA
- Correspondence:
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Membrilla-Fernández E, Gómez-Zorrilla S, González-Castillo AM, Pelegrina-Manzano A, Guzmán-Ahumada J, Prim N, Echeverria-Esnal D, Grau-Cerrato S, Horcajada-Gallego JP, Badía Pérez JM, Sancho-Insenser JJ. Evidencia científica de la duración del tratamiento antibiótico en las infecciones intraabdominales con control de foco quirúrgico. Cir Esp 2022. [DOI: 10.1016/j.ciresp.2022.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Boerman AW, Schinkel M, Meijerink L, van den Ende ES, Pladet LC, Scholtemeijer MG, Zeeuw J, van der Zaag AY, Minderhoud TC, Elbers PWG, Wiersinga WJ, de Jonge R, Kramer MH, Nanayakkara PWB. Using machine learning to predict blood culture outcomes in the emergency department: a single-centre, retrospective, observational study. BMJ Open 2022; 12:e053332. [PMID: 34983764 PMCID: PMC8728456 DOI: 10.1136/bmjopen-2021-053332] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES To develop predictive models for blood culture (BC) outcomes in an emergency department (ED) setting. DESIGN Retrospective observational study. SETTING ED of a large teaching hospital in the Netherlands between 1 September 2018 and 24 June 2020. PARTICIPANTS Adult patients from whom BCs were collected in the ED. Data of demographic information, vital signs, administered medications in the ED and laboratory and radiology results were extracted from the electronic health record, if available at the end of the ED visits. MAIN OUTCOME MEASURES The primary outcome was the performance of two models (logistic regression and gradient boosted trees) to predict bacteraemia in ED patients, defined as at least one true positive BC collected at the ED. RESULTS In 4885 out of 51 399 ED visits (9.5%), BCs were collected. In 598/4885 (12.2%) visits, at least one of the BCs was true positive. Both a gradient boosted tree model and a logistic regression model showed good performance in predicting BC results with area under curve of the receiver operating characteristics of 0.77 (95% CI 0.73 to 0.82) and 0.78 (95% CI 0.73 to 0.82) in the test sets, respectively. In the gradient boosted tree model, the optimal threshold would predict 69% of BCs in the test set to be negative, with a negative predictive value of over 94%. CONCLUSIONS Both models can accurately identify patients with low risk of bacteraemia at the ED in this single-centre setting and may be useful to reduce unnecessary BCs and associated healthcare costs. Further studies are necessary for validation and to investigate the potential clinical benefits and possible risks after implementation.
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Affiliation(s)
- Anneroos W Boerman
- Section General and Acute Internal Medicine, Department of Internal Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
- Department of Clinical Chemistry, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
| | - Michiel Schinkel
- Section General and Acute Internal Medicine, Department of Internal Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
- Center for Experimental and Molecular Medicine, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
| | | | - Eva S van den Ende
- Section General and Acute Internal Medicine, Department of Internal Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
| | - Lara Ca Pladet
- Section General and Acute Internal Medicine, Department of Internal Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
| | | | | | - Anuschka Y van der Zaag
- Section General and Acute Internal Medicine, Department of Internal Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
| | - Tanca C Minderhoud
- Section General and Acute Internal Medicine, Department of Internal Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
| | - Paul W G Elbers
- Department of Intensive Care Medicine, Amsterdam Medical Data Science, Amsterdam Cardiovascular Science, Amsterdam Infection and Immunity Institute, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
| | - W Joost Wiersinga
- Center for Experimental and Molecular Medicine, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
- Section Infectious Diseases, Department of Internal Medicine, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
| | - Robert de Jonge
- Department of Clinical Chemistry, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
| | - Mark Hh Kramer
- Board of Directors, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Prabath W B Nanayakkara
- Section General and Acute Internal Medicine, Department of Internal Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
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Creedon M, Humphreys H, Connolly R, Gaughan L, Skally M, Caird J, Duddy J, O'Halloran P, Mandiwanza T, Burns K, Dinesh B, Smyth E, O'Connell K, Fitzpatrick F. Multidisciplinary neurosurgical rounds incorporating antimicrobial stewardship. Are they of benefit? BRAIN AND SPINE 2022; 2:100885. [PMID: 36248101 PMCID: PMC9560698 DOI: 10.1016/j.bas.2022.100885] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 03/23/2022] [Accepted: 03/27/2022] [Indexed: 01/01/2023]
Abstract
Background In an era of increasing antimicrobial resistance, appropriate antimicrobials are essential to optimise patient outcomes. In 2017, antimicrobial use prevalence (AMU) on the two neurosurgical wards in our tertiary teaching hospital varied from 23% on ward A to 33% on ward B with 67% and 100% ‘appropriate’ prescriptions, respectively. In July 2018, a weekly antimicrobial stewardship multidisciplinary round led by a senior neurosurgery registrar commenced, attended by the antimicrobial stewardship team (AST). Research question This report evaluates whether a multi-disciplinary approach on neurosurgical prescribing was beneficial, specifically in reducing AMU. Materials and methods The following data was collected on AST rounds for 30 weeks in total from August 2018 to July 2019: number of patients on antimicrobials, appropriateness and stewardship actions. A questionnaire was distributed to neurosurgical doctors on two occasions to canvass opinions and attitudes on antimicrobial prescribing. Results 1716 prescriptions were reviewed (mean 57.2 per week). Of these 321 (18.7%) included antimicrobial prescriptions; 200 on ward A (19.8%), and 121 on ward B (17%), representing a decrease in AMU from 2017. The majority of antimicrobial prescriptions, 271 (84.4%) were deemed appropriate. Stewardship actions were taken in 215 (67%) prescriptions. Fifteen questionnaires were completed by neurosurgical doctors. The majority, 87%, stated the AST round was helpful overall. 93% indicated that informal training on the AST round was a source of education in antibiotic prescribing. Discussion and conclusion The weekly AST round provided a timely opportunity for multidisciplinary discussion, implementation of antimicrobial stewardship actions and opportunistic antimicrobial stewardship education. Surgeons need to be directly involved in antimicrobial stewardship to optimise patient outcomes and reduce antimicrobial resistance. A multidisciplinary antimicrobial stewardship (AST) ward round led by neurosurgery commenced in our hospital in 2018. Antimicrobial stewardship actions were taken in 67% of prescriptions, and antimicrobial use prevalence reduced in 2018 compared to 2017. A questionnaire distributed to neurosurgical doctors on the value of the AST round indicated that 87% of neurosurgical doctors found it helpful. We believe leadership and accountability were crucial to the success of the ward round, as neurosurgeons contributed directly to decision making.
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Gruenberg K, Abdoler E, O'Brien BC, Schwartz BS, MacDougall C. How do pharmacists select antimicrobials? A model of pharmacists' therapeutic reasoning processes. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2021. [DOI: 10.1002/jac5.1580] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Katherine Gruenberg
- Department of Clinical Pharmacy University of California San Francisco San Francisco California USA
| | - Emily Abdoler
- Department of Medicine University of Michigan Ann Arbor Michigan USA
| | - Bridget C. O'Brien
- Department of Medicine University of California San Francisco San Francisco California USA
| | - Brian S. Schwartz
- Department of Medicine University of California San Francisco San Francisco California USA
| | - Conan MacDougall
- Department of Clinical Pharmacy University of California San Francisco San Francisco California USA
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Nampoothiri V, Bonaconsa C, Surendran S, Mbamalu O, Nambatya W, Ahabwe Babigumira P, Ahmad R, Castro-Sanchez E, Broom A, Szymczak J, Zingg W, Gilchrist M, Holmes A, Mendelson M, Singh S, McLeod M, Charani E. What does antimicrobial stewardship look like where you are? Global narratives from participants in a massive open online course. JAC Antimicrob Resist 2021; 4:dlab186. [PMID: 34988443 PMCID: PMC8713011 DOI: 10.1093/jacamr/dlab186] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 11/05/2021] [Indexed: 11/13/2022] Open
Abstract
Background Whilst antimicrobial stewardship (AMS) is being implemented globally, contextual differences exist. We describe how the use of a massive open online course (MOOC) platform provided an opportunity to gather diverse narratives on AMS from around the world. Methods A free 3 week MOOC titled ‘Tackling antimicrobial resistance: a social science approach’ was launched in November 2019. Learners were asked specific questions about their experiences of AMS via 38 optional free-text prompts dispersed throughout the modules. Content analysis was used to identify key emerging themes from the learners’ responses in the first three runs of the MOOC. Results Between November 2019 and July 2020, 1464 learners enrolled from 114 countries. Overall, 199 individual learners provided a total of 1097 responses to the prompts. The diverse perspectives describe unique challenges present in different contexts including ill-defined roles for pharmacists and nurses in AMS; inadequate governance and policy inconsistencies in surveillance for antibiotic consumption and antimicrobial resistance (AMR) in some countries; lack of ownership of antibiotic decision-making and buy-in from different clinical specialties; and human resource and technological constraints. Patients’ knowledge, experiences and perspectives were recognized as a valuable source of information that should be incorporated in AMS initiatives to overcome cultural barriers to the judicious use of antibiotics. Conclusions Analysis of learner comments and reflections identified a range of enablers and barriers to AMS implementation across different healthcare economies. Common challenges to AMS implementation included the role of non-physician healthcare workers, resource limitations, gaps in knowledge of AMR, and patient engagement and involvement in AMS.
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Affiliation(s)
| | | | - Surya Surendran
- Department of Infection Control and Epidemiology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham University, Kochi, Kerala, India
| | - Oluchi Mbamalu
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Winnie Nambatya
- Department of Pharmacy, Makerere University, Kampala, Uganda
| | | | - Raheelah Ahmad
- Division of Health Services Research and Management, School of Health Sciences, University of London, London, UK
| | - Enrique Castro-Sanchez
- Division of Health Services Research and Management, School of Health Sciences, University of London, London, UK
| | - Alex Broom
- Department of Sociology and Social Policy, School of Social and Political Sciences, The University of Sydney, Sydney, Australia
| | - Julia Szymczak
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Walter Zingg
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, Zurich, Switzerland
| | - Mark Gilchrist
- Department of Pharmacy, Imperial College Healthcare NHS Trust, London, UK
| | - Alison Holmes
- Health Protection Research Unit in Healthcare Associated infections and Antimicrobial Resistance, Department of Medicine, Imperial College London, London, UK
| | - Marc Mendelson
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Sanjeev Singh
- Department of Infection Control and Epidemiology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham University, Kochi, Kerala, India
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Hampton T, Ogden J, Higgins HM. Understanding doctors' emergency department antibiotic prescribing decisions in children with respiratory symptoms in the UK: a qualitative study. BMJ Open 2021; 11:e051561. [PMID: 34930732 PMCID: PMC8688728 DOI: 10.1136/bmjopen-2021-051561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE Exploration of the factors that influence hospital doctors' antibiotic prescribing decisions when treating children with respiratory symptoms in UK emergency departments. METHODS A qualitative study using semistructured interviews based on a critical incident technique with 21 physicians of different grades and specialties that treat children in the UK. Interviews were audio-recorded then transcribed verbatim and analysed using thematic analysis. RESULTS Four themes were identified. These themes illustrate factors which influence clinician prescribing. The three principal themes were authorities, pressures and risk. The fourth transcending theme that ran through all themes was clinician awareness and complicity ('knowing but still doing'). CONCLUSIONS Hospital doctors prescribe antibiotics even when they know they should not. This appears to be due to the influence of those in charge or external pressures experienced while weighing up the immediate and longer term risks but clinicians do this with full insight into their actions. These findings have implications for invested parties seeking to develop future antimicrobial stewardship programmes. It is recommended that stewardship interventions acknowledge and target these themes which may in turn facilitate behaviour change and antimicrobial prescribing practice in emergency departments.
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Affiliation(s)
- Thomas Hampton
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Jane Ogden
- School of Psychology, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Helen Mary Higgins
- Department of Livestock and One Health, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
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Menz BD, Charani E, Gordon DL, Leather AJM, Moonesinghe SR, Phillips CJ. Surgical Antibiotic Prophylaxis in an Era of Antibiotic Resistance: Common Resistant Bacteria and Wider Considerations for Practice. Infect Drug Resist 2021; 14:5235-5252. [PMID: 34908856 PMCID: PMC8665887 DOI: 10.2147/idr.s319780] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 11/19/2021] [Indexed: 01/19/2023] Open
Abstract
The increasing incidence of antimicrobial resistance (AMR) presents a global crisis to healthcare, with longstanding antimicrobial agents becoming less effective at treating and preventing infection. In the surgical setting, antibiotic prophylaxis has long been established as routine standard of care to prevent surgical site infection (SSI), which remains one of the most common hospital-acquired infections. The growing incidence of AMR increases the risk of SSI complicated with resistant bacteria, resulting in poorer surgical outcomes (prolonged hospitalisation, extended durations of antibiotic therapy, higher rates of surgical revision and mortality). Despite these increasing challenges, more data are required on approaches at the institutional and patient level to optimise surgical antibiotic prophylaxis in the era of antibiotic resistance (AR). This review provides an overview of the common resistant bacteria encountered in the surgical setting and covers wider considerations for practice to optimise surgical antibiotic prophylaxis in the perioperative setting.
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Affiliation(s)
- Bradley D Menz
- SA Pharmacy, Flinders Medical Centre, Southern Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Esmita Charani
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa.,National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Department of Medicine, Imperial College London, London, UK
| | - David L Gordon
- Flinders Health & Medical Research Institute, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia.,Division of Medicine, Flinders Medical Centre, Southern Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Andrew J M Leather
- Centre for Global Health and Health Partnerships, School of Population Health and Environmental Science, Kings College London, London, UK
| | - S Ramani Moonesinghe
- Centre for Perioperative Medicine, UCL Division of Surgery and Interventional Science, London, UK.,UCL Hospitals NIHR Biomedical Research Centre, London, UK
| | - Cameron J Phillips
- SA Pharmacy, Flinders Medical Centre, Southern Adelaide Local Health Network, Adelaide, South Australia, Australia.,Flinders Health & Medical Research Institute, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia.,Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, Australia
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47
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Umarje SP, Alexander CG, Cohen AJ. Ambulatory Fluoroquinolone Use in the United States, 2015-2019. Open Forum Infect Dis 2021; 8:ofab538. [PMID: 34901300 DOI: 10.1093/ofid/ofab538] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 10/20/2021] [Indexed: 11/14/2022] Open
Abstract
Background Frequently used fluoroquinolones have been subject to increasing safety concerns and regulatory alerts. This study characterized ambulatory fluoroquinolone utilization in the United States and evaluated the impact of 2016 Food and Drug Administration (FDA) safety advisories on its use. Methods We used IQVIA's National Disease and Therapeutic Index to quantify adult outpatient fluoroquinolone use ("treatment visits"). Descriptive statistics and segmented regression were used to report trends and quantify the varied use before and after FDA's 2016 alerts. Results Between 2015 to 2019, fluoroquinolone use decreased by 26.7% (18.7 million treatment visits in 2015 to 13.7 million treatment visits in 2019). Annual use declined by 44%, 24%, and 24% for respiratory, urogenital, and gastrointestinal conditions, respectively; and by 66% among providers ≤44 years old vs negligible decline among those ≥65 years old. Before 2016 FDA advisories, there were approximately 4.8 million fluoroquinolone treatment visits/quarter, which had a statistically significant immediate drop by 641035 visits (95% confidence interval [CI], -937368 to -344702; P=.000) after FDA's 2016 advisories. A statistically significant difference of approximately 45000 visits/quarter (95% CI, -85956 to -3122; P=.036) was observed after the advisories. Conclusions Large reductions in ambulatory fluoroquinolone use in the United States have coincided with increasing evidence of safety concerns and FDA advisories. However, fluoroquinolone use varies significantly based on patient and provider characteristics, suggesting heterogeneous effects of emerging risks on clinical practice.
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Affiliation(s)
- Siddhi Pramod Umarje
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Caleb G Alexander
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Division of General Internal Medicine, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Andrew J Cohen
- The Brady Urological Institute at Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA
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48
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Gruber MM, Weber A, Jung J, Werner J, Draenert R. Impact and Sustainability of Antibiotic Stewardship on Antibiotic Prescribing in Visceral Surgery. Antibiotics (Basel) 2021; 10:antibiotics10121518. [PMID: 34943730 PMCID: PMC8698864 DOI: 10.3390/antibiotics10121518] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 12/07/2021] [Accepted: 12/09/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Antibiotic stewardship (AS) ward rounds are a core element in clinical care for surgical patients. Therefore, we aimed to analyze the impact of surgical AS ward rounds on antibiotic prescribing, and the sustainability of the effect after the AS interventions are no longer provided. METHODS On four wards of the department of visceral surgery, we conducted two independent retrospective prescribing analyses (P1, P2) over three months each. During the study periods, the level of AS intervention differed for two of the four wards (ward rounds/no ward rounds). RESULTS AS ward rounds were associated with a decrease in overall antibiotic consumption (91.1 days of therapy (DOT)/100 patient days (PD) (P1), 70.4 DOT/100PD (P2)), and improved de-escalation rates of antibiotic therapy (W1/2: 25.7% (P1), 40.0% (P2), p = 0.030; W3: 15.4 (P1), 24.2 (P2), p = 0.081). On the ward where AS measures were no longer provided, overall antibiotic usage remained stable (71.3 DOT/100PD (P1), 74.4 DOT/100PD (P2)), showing the sustainability of AS measures. However, the application of last-resort compounds increased from 6.4 DOT/100PD to 12.1 DOT/100PD (oxazolidinones) and from 10.8 DOT/100PD to 13.2 DOT/100PD (carbapenems). CONCLUSIONS Antibiotic consumption can be reduced without negatively affecting patient outcomes. However, achieving lasting positive changes in antibiotic prescribing habits remains a challenge.
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Affiliation(s)
- Magdalena Monika Gruber
- Antibiotic Stewardship Team, University Hospital, LMU Munich, 81377 München, Germany; (M.M.G.); (A.W.); (J.J.)
- Hospital Pharmacy, University Hospital, LMU Munich, 81377 München, Germany
| | - Alexandra Weber
- Antibiotic Stewardship Team, University Hospital, LMU Munich, 81377 München, Germany; (M.M.G.); (A.W.); (J.J.)
- Hospital Pharmacy, University Hospital, LMU Munich, 81377 München, Germany
| | - Jette Jung
- Antibiotic Stewardship Team, University Hospital, LMU Munich, 81377 München, Germany; (M.M.G.); (A.W.); (J.J.)
- Max von Pettenkofer Institute, Faculty of Medicine, LMU Munich, 81377 München, Germany
| | - Jens Werner
- Department of General, Visceral und Transplantation Surgery, University Hospital, LMU Munich, 81377 München, Germany;
| | - Rika Draenert
- Antibiotic Stewardship Team, University Hospital, LMU Munich, 81377 München, Germany; (M.M.G.); (A.W.); (J.J.)
- Correspondence:
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49
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Charani E, Mendelson M, Ashiru-Oredope D, Hutchinson E, Kaur M, McKee M, Mpundu M, Price JR, Shafiq N, Holmes A. Navigating sociocultural disparities in relation to infection and antibiotic resistance-the need for an intersectional approach. JAC Antimicrob Resist 2021; 3:dlab123. [PMID: 34604747 PMCID: PMC8485076 DOI: 10.1093/jacamr/dlab123] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
One of the key drivers of antibiotic resistance (ABR) and drug-resistant bacterial infections is the misuse and overuse of antibiotics in human populations. Infection management and antibiotic decision-making are multifactorial, complex processes influenced by context and involving many actors. Social constructs including race, ethnicity, gender identity and cultural and religious practices as well as migration status and geography influence health. Infection and ABR are also affected by these external drivers in individuals and populations leading to stratified health outcomes. These drivers compromise the capacity and resources of healthcare services already over-burdened with drug-resistant infections. In this review we consider the current evidence and call for a need to broaden the study of culture and power dynamics in healthcare through investigation of relative power, hierarchies and sociocultural constructs including structures, race, caste, social class and gender identity as predictors of health-providing and health-seeking behaviours. This approach will facilitate a more sustainable means of addressing the threat of ABR and identify vulnerable groups ensuring greater inclusivity in decision-making. At an individual level, investigating how social constructs and gender hierarchies impact clinical team interactions, communication and decision-making in infection management and the role of the patient and carers will support better engagement to optimize behaviours. How people of different race, class and gender identity seek, experience and provide healthcare for bacterial infections and use antibiotics needs to be better understood in order to facilitate inclusivity of marginalized groups in decision-making and policy.
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Affiliation(s)
- Esmita Charani
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
- Corresponding author. E-mail:
| | - Marc Mendelson
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | | | | | - Manmeet Kaur
- Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Martin McKee
- London School of Hygiene and Tropical Medicine, London, UK
| | - Mirfin Mpundu
- International Centre for Antimicrobial Resistance Solutions, Lusaka, Zambia
| | - James R Price
- Imperial College Healthcare NHS Trust, Department of Infectious Diseases, London, UK
| | - Nusrat Shafiq
- Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Alison Holmes
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
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50
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Kooda K, Bellolio F, Dierkhising R, Tande AJ. Defining Antibiotic Inertia: Application of a Focused Clinical Scenario Survey to Illuminate A New Target for Antimicrobial Stewardship During Transitions of Care. Clin Infect Dis 2021; 74:2050-2052. [PMID: 34596206 DOI: 10.1093/cid/ciab872] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Indexed: 11/13/2022] Open
Abstract
In clinical scenario surveys, inpatient providers were more likely to continue inappropriate antibiotic therapy (OR 2.02; 95% CI 1.35-3.03, p<0.001) or broad therapy (OR 1.8; 95%CI 1.27-2.56, p=0.001) when initiated by ED providers, as compared to appropriate or narrow antibiotics, respectively. Antibiotic inertia could represent a significant antibiotic stewardship target.
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Affiliation(s)
- Kirstin Kooda
- Department of Pharmacy, Mayo Clinic, Rochester, MN, USA
| | | | - Ross Dierkhising
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN USA
| | - Aaron J Tande
- Department of Infectious Diseases, Mayo Clinic, Rochester, MN USA
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