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Knowles R, Chandler C, O’Neill S, Sharland M, Mays N. A systematic review of national interventions and policies to optimize antibiotic use in healthcare settings in England. J Antimicrob Chemother 2024; 79:1234-1247. [PMID: 38507232 PMCID: PMC11144483 DOI: 10.1093/jac/dkae061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 02/19/2024] [Indexed: 03/22/2024] Open
Abstract
OBJECTIVES To identify and assess the effectiveness of national antibiotic optimization interventions in primary and secondary care in England (2013-2022). METHODS A systematic scoping review was conducted. Literature databases (Embase and Medline) were used to identify interventions and evaluations. Reports included the UK AMR Strategy (2013-2018), National Action Plan (2019-2024) and English Surveillance Programme for Antimicrobial Utilisation and Resistance (ESPAUR) reports (2014-2022). The design, focus and quality of evaluations and the interventions' effectiveness were extracted. FINDINGS Four hundred and seventy-seven peer-reviewed studies and 13 reports were screened. One hundred and three studies were included for review, identifying 109 interventions in eight categories: policy and commissioning (n = 9); classifications (n = 1); guidance and toolkits (n = 22); monitoring and feedback (n = 17); professional engagement and training (n = 19); prescriber tools (n = 12); public awareness (n = 17); workforce and governance (n = 12).Most interventions lack high-quality effectiveness evidence. Evaluations mainly focused on clinical, microbiological or antibiotic use outcomes, or intervention implementation, often assessing how interventions were perceived to affect behaviour. Only 16 interventions had studies that quantified effects on prescribing, of which six reported reductions. The largest reduction was reported with structural-level interventions and attributed to a policy and commissioning intervention (primary care financial incentives). Behavioural interventions (guidance and toolkits) reported the greatest impact in hospitals. CONCLUSIONS Many interventions have targeted antibiotic use, each pulling different levers across the health system simultaneously. On the basis of these studies, structural-level interventions may have the greatest impact. Collectively, the combination of interventions may explain England's decline in prescribing but direct evidence of causality is unavailable.
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Affiliation(s)
- Rebecca Knowles
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Clare Chandler
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Stephen O’Neill
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Mike Sharland
- Centre for Neonatal and Paediatric Infection, Institute for Infection and Immunity, St George’s, University of London, London, UK
- Paediatric Infectious Diseases Department, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Nicholas Mays
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Bergsholm YKR, Langaas HC, Krogstad T, Holm LB. Academic Detailing is a Preferred Knowledge Update Tool Among Norwegian Pharmacists to Improve Antibiotic Counseling: Results From a Quantitative Study Employing the Provider Satisfaction With Academic Detailing (PSAD) and the Detailer Assessment of Visit Effectiveness (DAVE) Tools. INQUIRY : A JOURNAL OF MEDICAL CARE ORGANIZATION, PROVISION AND FINANCING 2024; 61:469580241273228. [PMID: 39229667 PMCID: PMC11375677 DOI: 10.1177/00469580241273228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/05/2024]
Abstract
Excessive and incorrect use of antibiotics contributes to the rise of antimicrobial resistance (AMR). Given that pharmacists act as final checkpoint before antibiotics is handled over to patients, they play a crucial role in promoting proper antibiotic use and ensuring treatment adherence. However, there is often a gap between the patients' needs and perceptions, and what the pharmacists provide. Improving pharmacists' training is essential for enhancing patient-centered care. The aim of this research was to evaluate the suitability of academic detailing (AD) for improving Norwegian pharmacists' knowledge and practice on adherence promoting counseling of antibiotic patients. Key insights from prior qualitative research regarding community pharmacists' position in promoting optimized antibiotic use were incorporated in a tailored AD program. The AD's suitability was evaluated using the validated "Provider Satisfaction with Academic Detailing" (PSAD) and "Detailer Assessment of Visit Effectiveness" (DAVE) instruments. Additionally, participants preferred knowledge updates method were assessed. Eighty-one of 86 visits completed PSAD (94% response rate). Satisfaction summary score for PSAD was 40.03 (of maximum 45) and scale summary score for DAVE 12.45 (of maximum 15). One-sample t-test (P < .001) indicated preference for AD over other knowledge update methods. This study confirmed that AD is a successful knowledge updating tool for improving adherence promoting counseling among Norwegian pharmacists. Future research should align practice change intentions with actions post-AD and evaluate patient impact.
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Affiliation(s)
| | | | - Tonje Krogstad
- Department of Life Sciences and health, Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
| | - Lene Berge Holm
- Department of Life Sciences and health, Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
- Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway
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Bergsholm YKR, Feiring M, Charnock C, Krogstad T, Holm LB. Positioning of community pharmacists in interactions with general practitioners and patients regarding prescribing and using antibiotics. J Interprof Care 2023; 37:886-895. [PMID: 37161732 DOI: 10.1080/13561820.2023.2203698] [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: 03/28/2022] [Revised: 01/12/2023] [Accepted: 04/06/2023] [Indexed: 05/11/2023]
Abstract
Interprofessional collaboration between general practitioners (GPs) and community pharmacists (CPs) is important for ensuring antibiotics are used correctly and combating antibiotic resistance. The study's main objective was to investigate how CPs, GPs and patients, respectively, position CPs in their interactions with patients on antibiotic-related matters in Norwegian pharmacies. Seven focus-group interviews were performed. Data were analyzed using systematic text condensation. Positioning theory was used to identify positions assigned to CPs by themselves, by GPs and by patients. CPs position themselves as helpful, accessible drug specialists responsible for advising on antibiotic use, but also consider themselves dependent on GP-supplied information to do so. GPs position CPs as helpful, responsible businesspeople who, however, lack clinical experience and are overzealous gatekeepers. Patients position CPs as helpful people who supply information in "everyday language" and as the GP's extended arm. Patients utter they are best served when GPs and CPs collaborate. This discrepancy is a barrier to optimal service to patients in general, and to proper antibiotic use in particular.
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Affiliation(s)
| | - Marte Feiring
- Department of Rehabilitation Science and Health Technology, Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
| | - Colin Charnock
- Department of Life Sciences and health, Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
| | - Tonje Krogstad
- Department of Life Sciences and health, Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
| | - Lene Berge Holm
- Department of Life Sciences and health, Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
- Centre for Connected Care, Oslo University Hospital, Oslo, Norway
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Plaza Zamora FJ, Mendoza Barbero A, Molinero A, Sánchez Marcos N, Lambert M, Taxis K, García-Sangenis A, Llor C. [Audit of Antibiotic Dispensing in Community Pharmacy (Happy Patient Project)]. FARMACEUTICOS COMUNITARIOS 2023; 15:26-36. [PMID: 39156980 PMCID: PMC11326684 DOI: 10.33620/fc.2173-9218.(2023).28] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Accepted: 09/06/2023] [Indexed: 08/20/2024]
Abstract
Background Dispensing and prescribing antibiotics is inappropriate in many of the countries in the European Union, including Spain, and a threat to the population's health. To tackle the growth of antimicrobial resistance, the Happy Patient project was set up under the sponsorship of the European Commission. Aim O ascertain the characteristics of dispensing antibiotic therapy in Spanish community pharmacies.To compare the variability between different Spanish community pharmacies. Methods The Audit Project Odense® methodology was used to find out how antibiotics were dispensed in community pharmacies. Pharmacists taking part were asked to record for five consecutive days between the months of February and April 2022 the actions performed during the dispensing of oral antibiotics for human use and for the treatment of acute infections. Results A total population of 573 patients (59.9% female) of all age groups were interviewed. The patients were 83.6% aware of the purpose for which the antibiotic was prescribed and the most requested antibiotic was amoxicillin followed by amoxicillin with clavulanic acid.In 15% of dispensations, a triple safety check was completed: interactions, contraindications and allergies. The pharmacist rarely contacted the prescriber but when she did, the prescriber altered the prescription.In 62.3% of cases, information about the duration of treatment was provided and amoxicillin with and without clavulanic acid was the antibiotic dispensed for which most warnings about side effects were issued. In 24.6% of dispensations there was no advice given at all. In 81.7% the pharmacist agreed with the prescribed treatment. Conclusions This audit can be a starting point to improve clinical practice and reduce antibiotic resistance. It highlights the need for safety checks in regard to the use of antimicrobials and suggests verifying dispensing to correct errors that may jeopardize the safety and effectiveness of antimicrobial therapy.
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Affiliation(s)
- Francisco Javier Plaza Zamora
- Farmacéutico Comunitario en Mazarrón (Murcia). Doctor en Farmacia. Miembro del Grupo de Trabajo de Enfermedades Infecciosas e Inmunología de SEFACSociedad Española de Farmacia Clínica, Familiar y Comunitaria España
| | - Ana Mendoza Barbero
- Farmacéutica comunitaria en Reus (Tarragona). Miembro del Grupo de trabajo de Respiratorio y tabaquismo de SEFACSociedad Española de Farmacia Clínica, Familiar y Comunitaria España
| | - Ana Molinero
- Farmacéutica Comunitaria en Fuenlabrada (Madrid). Doctora en Farmacia. Miembro del Grupo de Trabajo de Enfermedades Infecciosas e Inmunología de SEFAC Sociedad Española de Farmacia Clínica, Familiar y Comunitaria España
| | - Navidad Sánchez Marcos
- Farmacéutica comunitaria en San Sebastián de los Reyes (Madrid). Miembro del Grupo de trabajo de Respiratorio y tabaquismo de SEFAC Sociedad Española de Farmacia Clínica, Familiar y Comunitaria España
| | - M Lambert
- Unit of PharmacoTherapy, Epidemiology and Economics, Groningen Research Institute of Pharmacy, University of Groningen, The NetherlandsUniversity of GroningenNetherlands
| | - Katja Taxis
- Unit of PharmacoTherapy, Epidemiology and Economics, Groningen Research Institute of Pharmacy, University of Groningen, 9713 AV Groningen, The Netherlands. University of GroningenNetherlands
| | - Ana García-Sangenis
- Fundació Institut Universitari per la Recerca a l’Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain. Centro de Investigación Biomédica en Red Enfermedades Infecciosas (CIBERINFEC)Centro de Investigación Biomédica en Red Enfermedades InfecciosasEspaña
| | - Carles Llor
- Fundació Institut Universitari per la Recerca a l’Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain. Centro de Investigación Biomédica en Red Enfermedades Infecciosas (CIBERINFEC)Centro de Investigación Biomédica en Red Enfermedades InfecciosasEspaña
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Ashiru-Oredope D, Cunningham N, Casale E, Muller-Pebody B, Hope R, Brown CS, Hopkins S. Reporting England's progress towards the ambitions in the UK action plan for antimicrobial resistance: the English surveillance programme for antimicrobial utilisation and resistance (ESPAUR). J Antimicrob Chemother 2023; 78:2387-2391. [PMID: 37596897 DOI: 10.1093/jac/dkad248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/21/2023] Open
Abstract
The plans for a new antimicrobial utilization and resistance national surveillance programme, alongside the development of quality measures and methods to monitor unintended outcomes of antimicrobial stewardship and both public and professional behaviour interventions were published in 2013. Since then, England has published an annual surveillance report including outlining progress against the ambitions of the UK national action plans on antimicrobial resistance (2013 to 2018 and 2019 to 2024). A decade later we provide a brief update on progress so far, with a focus on key highlights from the latest report published in November 2022. We also provide our recommendations for areas of focus as we move into the next decade. From an initial focus on antibiotic consumption and resistance, the report now includes surveillance data for antifungals, antivirals (including novel agents, such as those targeting SARS-CoV-2) and antimalarials. Evaluation of key stewardship interventions including professional and public engagement initiatives are also reported, as well as progress against NHS England's (NHSE's) improvement measures.
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Affiliation(s)
- Diane Ashiru-Oredope
- Healthcare-Associated Infection (HCAI), Fungal, Antimicrobial Resistance (AMR), Antimicrobial Use (AMU) & Sepsis Division, Clinical and Public Health Group, United Kingdom Health Security Agency (UKHSA), London, UK
| | - Neil Cunningham
- Clinical and Public Health Group, United Kingdom Health Security Agency (UKHSA), London, UK
| | - Ella Casale
- Healthcare-Associated Infection (HCAI), Fungal, Antimicrobial Resistance (AMR), Antimicrobial Use (AMU) & Sepsis Division, Clinical and Public Health Group, United Kingdom Health Security Agency (UKHSA), London, UK
| | - Berit Muller-Pebody
- Healthcare-Associated Infection (HCAI), Fungal, Antimicrobial Resistance (AMR), Antimicrobial Use (AMU) & Sepsis Division, Clinical and Public Health Group, United Kingdom Health Security Agency (UKHSA), London, UK
| | - Russell Hope
- Healthcare-Associated Infection (HCAI), Fungal, Antimicrobial Resistance (AMR), Antimicrobial Use (AMU) & Sepsis Division, Clinical and Public Health Group, United Kingdom Health Security Agency (UKHSA), London, UK
| | - Colin S Brown
- Healthcare-Associated Infection (HCAI), Fungal, Antimicrobial Resistance (AMR), Antimicrobial Use (AMU) & Sepsis Division, Clinical and Public Health Group, United Kingdom Health Security Agency (UKHSA), London, UK
| | - Susan Hopkins
- Clinical and Public Health Group, United Kingdom Health Security Agency (UKHSA), London, UK
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Cao W, Feng H, Ma Y, Zhao D, Hu X. Long-term trend of antibiotic use at public health care institutions in northwest China, 2012-20 -- a case study of Gansu Province. BMC Public Health 2023; 23:27. [PMID: 36604660 PMCID: PMC9814306 DOI: 10.1186/s12889-022-14944-6] [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: 05/06/2022] [Accepted: 12/26/2022] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Over the past 20 years, excessive antibiotic use has led to serious antimicrobial resistance (AMR) worldwide, and the phenomenon is particularly serious in China. To this end, the Chinese health sector took a series of measures to promote rational antibiotic use. In this study, to reveal the impact of policies on antibiotic use, we explored the long-term trend and patterns of antibiotic use at public health care institutions from 2012 to 2020 in northwest China, taking Gansu Province as an example. METHODS Antibiotic procurement data were obtained from the provincial centralized bidding procurement (CBP) platform between 2012 and 2020. Antibiotic use was quantified using the Anatomical Therapeutic Chemical (ATC)/defined daily doses (DDD) methodology and standardized using the DDD per 1000 inhabitants per day (DID). Twelve relevant quality indicators were calculated for comparison with the European Surveillance of Antimicrobial Consumption (ESAC) project monitoring results. RESULTS Total antibiotic use increased from 18.75 DID to 57.07 DID and then decreased to 19.11 DID, a turning point in 2014. The top three antibiotics used were J01C (beta-lactam antibacterials, penicillins), J01F (macrolides, lincosamides and streptogramins), and J01D (other beta-lactam antibacterials, cephalosporins), accounting for 45.15%, 31.40%, and 11.99% respectively. The oral antibiotics used were approximately 2.5 times the parenteral antibiotics, accounting for 71.81% and 28.19%, respectively. Different use preferences were shown in public hospitals and primary health care centres (PHCs), and the latter accounted for more than half of total use. The absolute use of all classes of antibiotics in Gansu is almost higher than any of the 31 European countries included in the ESAC, but the relative use of some focused antibiotics is lower than theirs. CONCLUSIONS The intervention policies of the health department reduced antibiotic use in Gansu Province, but the proportion of broad-spectrum and parenteral antibiotics was still high. It is necessary to further improve the quality of antibiotic prescriptions and pay more attention to the rationality of antibiotic use in PHCs.
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Affiliation(s)
- Wenxuan Cao
- grid.32566.340000 0000 8571 0482School of Public Health, Lanzhou University, Lanzhou, 730000 China
| | - Hu Feng
- grid.32566.340000 0000 8571 0482School of Public Health, Lanzhou University, Lanzhou, 730000 China
| | - Yongheng Ma
- Division of Pharmaceutical Procurement, Gansu Public Resources Trading Center, Lanzhou, 730000 China
| | - Defang Zhao
- Division of Pharmaceutical Procurement, Gansu Public Resources Trading Center, Lanzhou, 730000 China
| | - Xiaobin Hu
- grid.32566.340000 0000 8571 0482School of Public Health, Lanzhou University, Lanzhou, 730000 China
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Siribhadra A, Ngamprasertchai T, Rattanaumpawan P, Lawpoolsri S, Luvira V, Pitisuttithum P. Antimicrobial Stewardship in Tropical Infectious Diseases: Focusing on Dengue and Malaria. Trop Med Infect Dis 2022; 7:tropicalmed7080159. [PMID: 36006251 PMCID: PMC9412681 DOI: 10.3390/tropicalmed7080159] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 07/23/2022] [Accepted: 07/28/2022] [Indexed: 11/17/2022] Open
Abstract
Acute undifferentiated febrile illness (AUFI) is the presenting symptom of various tropical and infectious diseases. Viral infection is generally the most common cause of AUFI, accounting for 8–11.8% of cases; thus, antibiotics might be unnecessary. Dengue and malaria are common tropical infectious diseases requiring effective supportive treatment and antimalarial agents, respectively. The uncertainty of early diagnosis results in widespread empirical antimicrobial treatment in high -income as well as in low-and middle-income countries. Although rapid diagnostic tests (RDTs) have been shown to limit antibiotic prescriptions in dengue and malaria, we observed a wide range of antibiotic prescriptions for 13–92.7% of cases in previous literature, particularly in RDT-negative malaria cases. Given several RDT limitations, antimicrobial stewardship (AMS) appears to be an effective strategy for controlling unnecessary antibiotic use and antimicrobial resistance (AMR) prevention. This program should be endorsed by a multidisciplinary team in tropical diseases to control collateral damage of inappropriate antimicrobial use. Empirical antibiotic treatment should be administered based on clinical judgement, microbiological evidence, and local epidemiological data. Rapid termination of antibiotic therapy, including disease control or elimination, is the mainstay of AMS in tropical diseases. Local and international sectors should implement an AMS programme to reduce AMR in the Tropics.
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Affiliation(s)
- Ashley Siribhadra
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand; (A.S.); (V.L.); (P.P.)
| | - Thundon Ngamprasertchai
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand; (A.S.); (V.L.); (P.P.)
- Correspondence:
| | - Pinyo Rattanaumpawan
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand;
| | - Saranath Lawpoolsri
- Department of Tropical Hygiene, Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand;
| | - Viravarn Luvira
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand; (A.S.); (V.L.); (P.P.)
| | - Punnee Pitisuttithum
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand; (A.S.); (V.L.); (P.P.)
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Shirazi OU, Ab Rahman NS, Zin CS. An overview of the hospitals’ antimicrobial stewardship programs implemented to improve antibiotics’ utilization, cost and resistance patterns. JOURNAL OF PHARMACY 2022. [DOI: 10.31436/jop.v2i1.76] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Introduction: The high reliance of the physicians and surgeons on the antibiotics since their discovery has led to an irrational antibiotic utilization which not only has raised the incidence of antimicrobial resistance (AMR) but also increased the cost of treatment with antibiotics as high use of antibiotics has been found related to the occurrence of certain nosocomial infections which need extra antibiotic courses to be cured. In order to overcome these antibiotic utilization related problems an antimicrobial stewardship (AMS) program being the set of various persuasive, restrictive and structural interventions is considered an effective tool to rationalize the in-patient antimicrobial utilization worldwide.
Method: The focus of this review is on the interventions that are being implemented during the in-patient AMS programs and have been described effective in controlling the antibiotic utilization, their cost of treatment and an overall infection control. The literature containing the information about various AMS interventions effecting the utilization and cost patterns along with the impact on AMR was searched in various databases such as PubMed, Google Scholar, Science Direct, Ovid (Medline) and Scopus. The categorical sorting of the published data is based on various AMS interventions such as the guideline development, formulary restriction (pre-authorization), educative interventions, clinical pathway development and prospective (post prescription) audit. Considering the objectives of the study such as the goal to curb overutilization of antibiotics, control of their cost of treatment for in-patients and infection control the sorted literature is presented in three different tables describing the AMS impact on the said outcomes.
Results: The post AMS changes in utilization patterns are described as fall of antibiotics defined daily doses (DDD) and days of therapy (DOT) which resulted in the reduction of the cost of treatment with antibiotics. The reduction of the cost of treatment with antibiotics also resulted due to the AMS impact on the control of various nosocomial and multi-drug resistant (MDR) infections.
Conclusion: It has been concluded that the AMS program if implemented under the supervision of an expert AMS team mainly comprising of an infectious disease (ID) physician, clinical pharmacists and microbiologists with considerable support by the hospital authorities could be a highly efficient tool of the pharmacovigilance for rationalizing the in-patient antimicrobial practice.
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Otieno PA, Campbell S, Maley S, Obinju Arunga T, Otieno Okumu M. A Systematic Review of Pharmacist-Led Antimicrobial Stewardship Programs in Sub-Saharan Africa. Int J Clin Pract 2022; 2022:3639943. [PMID: 36311485 PMCID: PMC9584722 DOI: 10.1155/2022/3639943] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 09/27/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The misuse of antibiotics contributes significantly to antimicrobial resistance (AMR). Higher treatment costs, longer hospital stays, and clinical failure can all result from AMR. According to projections, Africa and Asia will bear the heaviest burden of AMR-related mortalities in the coming years. Antimicrobial stewardship (AMS) programmes are therefore critical in mitigating the effects of AMR. Pharmacists may play an important role in such programmes, as seen in Europe and North America, but the impact, challenges, and opportunities of pharmacist-led antimicrobial stewardship interventions in Sub-Saharan African hospitals are unknown. The purpose of this systematic review was to assess the impact, challenges, and opportunities of pharmacist-led antimicrobial stewardship interventions in Sub-Saharan African hospitals. METHODS The Joanna Briggs Institute (JBI) guidelines were used to search for peer-reviewed pharmacist-led studies based in hospitals in Sub-Saharan Africa that were published in English between January 2015 and January 2021. The PubMed, Embase, and Ovid databases were used. RESULTS Education and training, audits and feedback, protocol development, and ward rounds were identified as primary components of pharmacist-led antimicrobial stewardship interventions in Sub-Saharan Africa. The pharmacist-led antimicrobial interventions improved adherence to guidelines and reduced inappropriate prescribing, but were hampered by a lack of laboratory and technological support, limited stewardship time, poor documentation, and a lack of guidelines and policies. Funding, mentorship, guidelines, accountability, continuous monitoring, feedback, multidisciplinary engagements, and collaborations were identified as critical in the implementation of pharmacist-led antimicrobial stewardship programmes. CONCLUSIONS These findings suggest that pharmacists in Sub-Saharan African hospitals can successfully lead antimicrobial stewardship programmes but their implementation is limited by lack of mentorship, accountability, continuous monitoring, feedback, collaborations, and poor funding.
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Affiliation(s)
- Phanice Ajore Otieno
- College of Medical, Veterinary and Life Sciences, School of Life Sciences, University of Glasgow, Glasgow, UK
- Department of Health, County Government of Kisumu, PO Box 2738-40100, Kisumu, Kenya
| | - Sue Campbell
- College of Medical, Veterinary and Life Sciences, School of Life Sciences, University of Glasgow, Glasgow, UK
| | - Sonny Maley
- College of Medical, Veterinary and Life Sciences, School of Life Sciences, University of Glasgow, Glasgow, UK
| | - Tom Obinju Arunga
- Department of Health Informatics, Maseno University, Private Bag, Kisumu, Kenya
| | - Mitchel Otieno Okumu
- Department of Health, County Government of Kisumu, PO Box 2738-40100, Kisumu, Kenya
- Department of Public Health Pharmacology and Toxicology, Faculty of Veterinary Medicine, University of Nairobi, PO Box 29053-00625, Nairobi, Kenya
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10
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Rout J, Essack S, Brysiewicz P. Guideline recommendations for antimicrobial stewardship education for clinical nursing practice in hospitals: A scoping review. SOUTHERN AFRICAN JOURNAL OF CRITICAL CARE 2021; 37:10.7196/SAJCC.2021.v37i3.482. [PMID: 35517853 PMCID: PMC9053417 DOI: 10.7196/sajcc.2021.v37i3.482] [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] [Accepted: 04/12/2021] [Indexed: 11/21/2022] Open
Abstract
Background Antimicrobial stewardship (AMS) is a proactive healthcare intervention to improve patient outcomes by optimising antimicrobial use. Although nursing involvement is a recognised necessity, bedside nurses may not yet possess competencies to fulfil this role. Objectives To identify recommendations for AMS education for the bedside nurse in key global AMS guidelines. Methods Scoping review methodology was used to systematically search published and 'grey' literature in PubMed, EBSCOhost, Google Scholar, government websites and websites of professional societies and organisations. Search dates were from 1990 to 2020. Inclusion criteria were English language AMS guidelines for hospitals. Results Literature searches retrieved 1 824 articles, with 43 meeting the review inclusion criteria. Reference was made to AMS nursing education in 23 (53.4%) of the articles. Educational opportunities for nurses were recommended: inclusion of AMS concepts/content into undergraduate and postgraduate nursing curricula (n=12; 27.9%), in-hospital training (n=14; 32.5%) and continuing professional development (n=6; 13.9%). Recommendations for nursing education were as follows: role of AMS in preventing antimicrobial resistance (n=7; 16.2%), infection prevention and control (n=3; 6.9%), diagnostics in AMS (n=5; 11.6%), pharmacology (n=11; 25.5%) and collaboration (n=2; 4.6%). Identified nursing educational gaps were: nurses not recognising their role within AMS (n=5; 11.6%), inadequate nursing resources and expertise for dosing, pharmacokinetic/pharmacodynamic strategies and managing possible drug incompatibilities with extended/prolonged infusions (n=3; 6.9%), and inappropriate nurse disposal of antibiotic waste (n=1; 2.3%). Conclusion Although recommendations for nursing education were found in many key AMS guidelines, few guidelines provided detailed descriptions of the nursing competencies that were required for this role. Contributions of the study This study serves to compile and highlight previously little-known recommendations within key international antimicrobial stewardship (AMS) guidelines for the education of clinical nurses in their AMS role. It provides a summary of expected clinical nurse competencies. It adds to current discussion within the literature on how to improve and support this critical nursing role.
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Affiliation(s)
- J Rout
- College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - S Essack
- College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - P Brysiewicz
- College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
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Saha SK, Kong DCM, Mazza D, Thursky K. A systems thinking approach for antimicrobial stewardship in primary care. Expert Rev Anti Infect Ther 2021; 20:819-827. [PMID: 34968161 DOI: 10.1080/14787210.2022.2023010] [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: 10/19/2022]
Abstract
INTRODUCTION The establishment of antimicrobial stewardship (AMS) in primary care is central to substantially reduce the antimicrobial use and the associated risk of resistance. This perspective piece highlights the importance of systems thinking to set up and facilitate AMS programs in primary care. AREAS COVERED The challenges that primary care faces to incorporate AMS programmes is multifactorial: an implementation framework, relevant resources, team composition, and system structures remain under-researched, and these issues are often overlooked and/or neglected in most parts of the world. Progress in the field remains slow in developed countries but potentially limited in low- and middle-income countries. EXPERT OPINION The key AMS strategies to optimize antimicrobial use in primary care are increasingly known; however, health system components that impact effective implementation of AMS programs remain unclear. We highlight the importance of systems thinking to identify and understand the resource arrangements, system structures, dynamic system behaviors, and intra- and interprofessional connections to optimally design and implement AMS programs in primary care. An AMS systems thinking systemigram (i.e. a visual representation of overall architecture of a system) could be a useful tool to foster AMS implementation in primary care.
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Affiliation(s)
- Sajal K Saha
- Department of General Practice, The School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,National Centre for Antimicrobial Stewardship (NCAS), Department of Infectious Diseases, Melbourne Medical School, University of Melbourne, Melbourne, Victoria, Australia.,Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Ellengowan Drive, Darwin, Australia
| | - David C M Kong
- National Centre for Antimicrobial Stewardship (NCAS), Department of Infectious Diseases, Melbourne Medical School, University of Melbourne, Melbourne, Victoria, Australia.,Centre for Medicine Use and Safety, Monash University, Victoria, Australia.,Pharmacy Department, Ballarat Health Services, Ballarat, Victoria, Australia
| | - Danielle Mazza
- Department of General Practice, The School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,National Centre for Antimicrobial Stewardship (NCAS), Department of Infectious Diseases, Melbourne Medical School, University of Melbourne, Melbourne, Victoria, Australia
| | - Karin Thursky
- National Centre for Antimicrobial Stewardship (NCAS), Department of Infectious Diseases, Melbourne Medical School, University of Melbourne, Melbourne, Victoria, Australia
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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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Feihl S, Querbach C, Hapfelmeier A, Busch DH, von Eisenhart-Rothe R, Gebhardt F, Pohlig F, Mühlhofer HML. Effect of an Intensified Antibiotic Stewardship Program at an Orthopedic Surgery Department. Surg Infect (Larchmt) 2021; 23:105-112. [PMID: 34762545 DOI: 10.1089/sur.2021.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Institutional programs such as antibiotic stewardship (ABS) programs offer possibilities to monitor and modify antibiotic usage with the aim of reducing antibiotic resistance. In orthopedic units that treat peri-prosthetic joint infections (PJIs), ABS programs are still rare, however, there is extensive use of high-risk antibiotic agents and an increased risk for the occurrence of Clostridium difficile infections (CDIs). Patients and Methods: An ABS program was implemented at the Department of Orthopedic Surgery at a university hospital. Quarterly antibiotic consumption was measured in defined daily doses (DDDs) per 100 patient-days (PDs) at 10 quarters before the intervention and seven quarters after the intervention. The effect of the new antibiotic policy on drug use rates was evaluated using an interrupted time-series analysis. Estimated changes over time in the incidence of CDIs (cases per 1,000 PDs) were analyzed. Results: A remarkable percentual reduction in second-generation cephalosporin use of 83% (p < 0.001; pre-intervention level, 81.486 DDDs/100 patient-days; post-intervention level, 13.751 DDDs/100 PDs) and clindamycin administration of 78% (p < 0.001; pre-intervention level, 18.982 DDDs/100 PDs; post-intervention level, 4.216 DDDs/100 PDs) was observed after implementation of ABS interventions. Total antibiotic use declined by 25% (p < 0.001; pre-intervention level, 129.078 DDDs/100 PDs; post-intervention level, 96.826 DDDs/100 PDs). Conclusions: This research assessed the positive impact of an intensified ABS program at an orthopedic department specializing in PJIs. Antibiotic stewardship program interventions encourage the reduction of total antibiotic usage and especially high-risk antibiotic agents, associated with the development of antimicrobial resistance.
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Affiliation(s)
- Susanne Feihl
- Institute for Medical Microbiology, Immunology and Hygiene, Statistics, Epidemiology, Technical University Munich, School of Medicine, Munich, Germany
| | - Christiane Querbach
- Pharmacy Department, University Hospital Klinikum rechts der Isar, Technical University Munich, School of Medicine, Munich, Germany
| | - Alexander Hapfelmeier
- Institute of Medical Informatics, Statistics, Epidemiology, Technical University Munich, School of Medicine, Munich, Germany
| | - Dirk H Busch
- Institute for Medical Microbiology, Immunology and Hygiene, Statistics, Epidemiology, Technical University Munich, School of Medicine, Munich, Germany
| | - Rüdiger von Eisenhart-Rothe
- Department of Orthopedic Surgery, University Hospital Klinikum rechts der Isar, Technical University Munich, School of Medicine, Munich, Germany
| | - Friedemann Gebhardt
- Institute for Medical Microbiology, Immunology and Hygiene, Statistics, Epidemiology, Technical University Munich, School of Medicine, Munich, Germany
| | - Florian Pohlig
- Department of Orthopedic Surgery, University Hospital Klinikum rechts der Isar, Technical University Munich, School of Medicine, Munich, Germany
| | - Heinrich M L Mühlhofer
- Department of Orthopedic Surgery, University Hospital Klinikum rechts der Isar, Technical University Munich, School of Medicine, Munich, Germany
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Ng V, Ashiru-Oredope D, Rosado H, Ward B. Outcomes of a National, Cross-Sector Antimicrobial Stewardship Training Initiative for Pharmacists in England. PHARMACY 2021; 9:165. [PMID: 34698272 PMCID: PMC8544733 DOI: 10.3390/pharmacy9040165] [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: 08/30/2021] [Revised: 09/29/2021] [Accepted: 10/01/2021] [Indexed: 12/02/2022] Open
Abstract
(1) Background: Pharmacists play a pivotal role in tackling Antimicrobial resistance through antimicrobial stewardship (AMS) and are well placed to lead behaviour change interventions across the healthcare system; (2) Methods: A cross-sector AMS training initiative for pharmacists was implemented across England, with three cohorts between 2019-2021. Each cohort took part in an introductory workshop, followed- by a workplace-based quality improvement project supported by peer-assisted learning sessions. Completion of training was determined by an end of training assessment after three to four months. Outcome data and learner survey results were collated, anonymised, and analysed by the training provider. (3) Results: In total, 118 pharmacists participated in the introductory workshop, 70% of these subsequently undertook an improvement project, and 48% engaged workplace stakeholders in the process. Interventions were designed by 57% of learners and 18% completed a at least one Plan-Do-Study-Act cycle. Approximately a quarter of learners met the requirements for a Certificate of Completion. Knowledge quiz scores were obtained from 115 learners pre-training and 28 learners post-training. Paired t-tests conducted for 28 learners showed a statistically significant improvement in mean score from 67.7% to 81.1% (p < 0.0001). Sixty-two learner survey responses were received during the training and 21 follow-up survey responses 6 to 12 months post training. Of the 21 responses to the follow-up survey, ongoing quality improvement work and improvement outcomes were reported by nine and six learners, respectively. (4) Conclusions: The delivery of workplace-based training at scale can be challenging, however this study demonstrates that coupling learning with workplace implementation and peer support can promote behaviour change in learners. Further study into the impact of providing pharmacists across sectors and geographies with access to this type of training will help inform ongoing workforce development interventions.
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Affiliation(s)
- Vincent Ng
- Royal Pharmaceutical Society, 66-68 East Smithfield, London E1W 1AW, UK; (V.N.); (H.R.)
| | - Diane Ashiru-Oredope
- HCAI, Fungal, AMR, AMU & Sepsis Division, UK Health Security Agency, London SE1 8UG, UK;
| | - Helena Rosado
- Royal Pharmaceutical Society, 66-68 East Smithfield, London E1W 1AW, UK; (V.N.); (H.R.)
| | - Beth Ward
- Royal Pharmaceutical Society, 66-68 East Smithfield, London E1W 1AW, UK; (V.N.); (H.R.)
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Hwang S, Kwon KT. Core Elements for Successful Implementation of Antimicrobial Stewardship Programs. Infect Chemother 2021; 53:421-435. [PMID: 34623776 PMCID: PMC8511365 DOI: 10.3947/ic.2021.0093] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 09/11/2021] [Indexed: 12/23/2022] Open
Abstract
Antimicrobial resistance has emerged as a serious global public health threat. One of the countermeasures to increased antibiotic-resistant bacterial infections is the use of an integrative intervention strategy for the selection and administration of appropriate antibiotics and for the monitoring of antibiotic use, collectively known as "Antimicrobial Stewardship Programs" (ASPs). However, since the medical environment and policies vary by country and medical facilities, ASPs also need to be applied to each facility and condition accordingly. The United States Centers for Disease Control and Prevention announced the core elements for hospital ASPs, which outlines the specific structural and procedural components required to implement ASPs in 2014. As multidrug-resistant bacterial infections and use of broad-spectrum antibiotics in Korea are on the rise, ASPs must be urgently applied to medical facilities for appropriate management of antibiotic use. However, there is an ongoing limitation to the immediate adoption and application of ASPs in Korean medical facilities due to the lack of medical workforce and related financial resources. To address this issue, efforts of medical professionals and government are required, and core elements that match the characteristics and circumstances of Korean medical facilities must be urgently developed.
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Affiliation(s)
- Soyoon Hwang
- Division of Infectious Diseases, Department of Internal Medicine, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Ki Tae Kwon
- Division of Infectious Diseases, Department of Internal Medicine, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea.
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16
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Rout J, Essack S, Brysiewicz P. Guidelines for the hospital role of the clinical nurse in antimicrobial stewardship: A scoping review. SOUTHERN AFRICAN JOURNAL OF CRITICAL CARE 2021; 37:10.7196/SAJCC.2021.v37i2.481. [PMID: 35493977 PMCID: PMC9045517 DOI: 10.7196/sajcc.2021.v37i2.481] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2021] [Indexed: 11/08/2022] Open
Abstract
Background Antimicrobial stewardship aims to optimise the use of antimicrobial medicines to preserve the efficacy of these medicines and to contain antimicrobial resistance where possible. Nurses constitute the largest group of healthcare workers; however, the role played by nurses within current antimicrobial stewardship strategies is largely unacknowledged despite nurses being at point-of-care at the hospital bedside. Objectives To identify recommendations for the antimicrobial stewardship role of the bedside nurse in key global antimicrobial stewardship guidelines. Methods Scoping review methodology was used to systematically search published and 'grey' literature in PubMed, EBSCOhost, Google Scholar, government websites, and websites of professional societies and organisations. Search dates were 1990 to 2020. Inclusion criteria were English language antimicrobial stewardship guidelines for hospitals. Screening was conducted in two stages for title and abstract and then full text relevancy and documented according to the PRISMA Extension for Scoping Reviews. Results Of the 1 824 articles that were retrieved, only 43 met the inclusion criteria. Inclusion of the bedside nurse on the antimicrobial stewardship team occurred in 13.9% (n=6) of the papers. A role for the bedside nurse was recommended in antibiotic stewardship (32.5%; n=14), infection prevention and control (23.2%; n=10), and administration of antimicrobial medicines (20.9%; n=9) of reviewed documents. Other recommendations included the use of evidence-based antimicrobial stewardship (20.9%; n=9), collaboration with other healthcare staff (11.6%; n=5), facilitation of transition of care (18.6%; n=8), and nurse prescription of antibiotics (4.6%; n=2). Conclusion This scoping review highlights a slow but incremental increase in recognition of the role of the bedside nurse within the operational hub of antimicrobial stewardship strategies. Contributions of the study The present study was undertaken to fill the gap in the literature on clinical nurses' contribution in antimicrobial stewardship. The findings of the review largely demonstrate that multidisciplinary antimicrobial stewardship guidelines fail to view the bedside nurse as a contributor within antimicrobial stewardship strategies.
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Affiliation(s)
- J Rout
- College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - S Essack
- Antimicrobial Research Unit, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - P Brysiewicz
- College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
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Borek AJ, Anthierens S, Allison R, McNulty CAM, Lecky DM, Costelloe C, Holmes A, Butler CC, Walker AS, Tonkin-Crine S. How did a Quality Premium financial incentive influence antibiotic prescribing in primary care? Views of Clinical Commissioning Group and general practice professionals. J Antimicrob Chemother 2021; 75:2681-2688. [PMID: 32573692 DOI: 10.1093/jac/dkaa224] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 04/24/2020] [Accepted: 04/27/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The Quality Premium (QP) was introduced for Clinical Commissioning Groups (CCGs) in England to optimize antibiotic prescribing, but it remains unclear how it was implemented. OBJECTIVES To understand responses to the QP and how it was perceived to influence antibiotic prescribing. METHODS Semi-structured telephone interviews were conducted with 22 CCG and 19 general practice professionals. Interviews were analysed thematically. RESULTS The findings were organized into four categories. (i) Communication: this was perceived as unstructured and infrequent, and CCG professionals were unsure whether they received QP funding. (ii) Implementation: this was influenced by available local resources and competing priorities, with multifaceted and tailored strategies seen as most helpful for engaging general practices. Many antimicrobial stewardship (AMS) strategies were implemented independently from the QP, motivated by quality improvement. (iii) Mechanisms: the QP raised the priority of AMS nationally and locally, and provided prescribing targets to aim for and benchmark against, but money was not seen as reinvested into AMS. (iv) Impact and sustainability: the QP was perceived as successful, but targets were considered challenging for a minority of CCGs and practices due to contextual factors (e.g. deprivation, understaffing). CCG professionals were concerned with potential discontinuation of the QP and prescribing rates levelling off. CONCLUSIONS CCG and practice professionals expressed positive views of the QP and associated prescribing targets and feedback. The QP helped influence change mainly by raising the priority of AMS and defining change targets rather than providing additional funding. To maximize impact, behavioural mechanisms of financial incentives should be considered pre-implementation.
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Affiliation(s)
- Aleksandra J Borek
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Rosalie Allison
- Primary Care and Interventions Unit, Public Health England, Gloucester, UK
| | | | - Donna M Lecky
- Primary Care and Interventions Unit, Public Health England, Gloucester, UK
| | - Ceire Costelloe
- Faculty of Medicine, School of Public Health, Imperial College London, London, UK
| | - Alison Holmes
- Department of Infectious Diseases, Imperial College London, London, UK.,National Institute for Health Research (NIHR) Health Protection Research Unit (HPRU) in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - A Sarah Walker
- National Institute for Health Research (NIHR) Health Protection Research Unit (HPRU) in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.,National Institute for Health Research (NIHR) Health Protection Research Unit (HPRU) in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
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Monmaturapoj T, Scott J, Smith P, Abutheraa N, Watson MC. Pharmacist-led education-based antimicrobial stewardship interventions and their effect on antimicrobial use in hospital inpatients: a systematic review and narrative synthesis. J Hosp Infect 2021; 115:93-116. [PMID: 34144096 DOI: 10.1016/j.jhin.2021.06.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 06/06/2021] [Accepted: 06/07/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Antimicrobial stewardship (AMS) programmes optimize antimicrobial use and address antimicrobial resistance. Pharmacists are often key agents of these programmes. The effectiveness of hospital-based AMS interventions when they are led by pharmacists, however, has not previously been reported. AIM To evaluate the effectiveness of pharmacist-led AMS interventions in improving antimicrobial use for hospital inpatients. METHODS Standard systematic review methods were used. The search strategies and databases used in a previous Cochrane review were applied. Studies that reported pharmacist-led AMS interventions were included. Narrative synthesis was used to report the findings. PRISMA guidelines were followed. FINDINGS From 6971 records retrieved and screened, 52 full-text articles were included. Most studies were undertaken in teaching hospitals (N = 45) and many were conducted in North America (N = 27). Most interventions targeted junior or ward physicians and lasted between one and six months. All studies evaluated educational interventions often in combination with other interventions and reported improvements 'in compliance with target AMS practice'. Greater compliance was achieved with multiple interventions. Pharmacist-led interventions reduced the duration of antimicrobial therapy without increasing mortality. No consistency of evidence was achieved in relation to interventions and reduced duration of hospital stay, nor infections due to antimicrobial resistance or occurrence of Clostridium difficile. CONCLUSION This is the first systematic review to evaluate the effectiveness of pharmacist-led AMS interventions in hospital inpatients. Education-based interventions were effective in increasing guideline compliance and reducing duration of antimicrobial therapy. Future hospital-based AMS programmes should consider the involvement of pharmacists to deliver and promote AMS interventions and programmes.
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Affiliation(s)
- T Monmaturapoj
- Department of Pharmacy and Pharmacology, University of Bath, Bath, UK.
| | - J Scott
- Department of Pharmacy and Pharmacology, University of Bath, Bath, UK
| | - P Smith
- Department of Psychology, University of Bath, Bath, UK
| | - N Abutheraa
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
| | - M C Watson
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
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Saha SK, Hawes L, Mazza D. Effectiveness of interventions involving pharmacists on antibiotic prescribing by general practitioners: a systematic review and meta-analysis. J Antimicrob Chemother 2021; 74:1173-1181. [PMID: 30698721 DOI: 10.1093/jac/dky572] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Revised: 12/19/2018] [Accepted: 12/20/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The use of community antibiotic stewardship programmes (ASPs) is rising; however, their effectiveness when pharmacists are involved is uncertain. OBJECTIVES To assess the effectiveness of ASPs involving pharmacists at improving antibiotic prescribing by general practitioners (GPs). METHODS Medline, Embase, Emcare, PubMed, PsycINFO, Cochrane CENTRAL, CINAHL Plus and Web of Science databases were searched to February 2018. Randomized and non-randomized studies of ASPs involving pharmacists as interventionists to GPs were included. Primary outcomes were absolute changes in GPs' antibiotic prescribing rate (APR) and antibiotic prescribing adherence rate (APAR) according to recommendations/guidelines. Meta-analysis used random effects models. RESULTS Fifteen studies reporting 18 trials were included in the meta-analysis: 8 assessed the APR and 10 the APAR. APR reductions (OR 0.86, 95% CI 0.78-0.95, moderate-certainty evidence) and APAR improvements (OR 1.96, 95% CI 1.56-2.45, high-certainty evidence) were observed at 6 months median intervention follow-up. High-quality randomized trials reduced the APR (OR 0.92, 95% CI 0.90-0.94) and increased the APAR (OR 2.55, 95% CI 2.16-3.01). Interventions were successful in decreasing the APR (OR 0.93, 95% CI 0.90-0.95) and increasing the APAR (OR 1.72, 95% CI 1.04-2.84) when implemented by a pharmacist-GP team. Interventions involving pharmacist-infectious disease professional teams also decreased the APR (OR 0.81, 95% CI 0.66-1.0) and increased the APAR (OR 2.36, 95% CI 1.87-2.96). GP education plus prescribing feedback, and group meetings were effective in both outcomes, whereas GP education, academic detailing and workshop training were effective in APAR outcome. However, substantial heterogeneity was demonstrated. CONCLUSIONS ASPs involving pharmacists are effective in decreasing antibiotic prescribing and increasing guideline-adherent antibiotic prescribing by GPs.
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Affiliation(s)
- Sajal K Saha
- Department of General Practice, Monash University, Building 1, 270 Ferntree Gully Road, Notting Hill, Victoria, VIC, Australia
- National Centre for Antimicrobial Stewardship (NCAS), The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Lesley Hawes
- Department of General Practice, Monash University, Building 1, 270 Ferntree Gully Road, Notting Hill, Victoria, VIC, Australia
- National Centre for Antimicrobial Stewardship (NCAS), The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Danielle Mazza
- Department of General Practice, Monash University, Building 1, 270 Ferntree Gully Road, Notting Hill, Victoria, VIC, Australia
- National Centre for Antimicrobial Stewardship (NCAS), The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
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Bhogal R, Hussain A, Balaji A, Bermingham WH, Marriott JF, Krishna MT. The role of a clinical pharmacist in spurious Penicillin allergy: a narrative review. Int J Clin Pharm 2021; 43:461-475. [PMID: 33439428 DOI: 10.1007/s11096-020-01226-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 12/30/2020] [Indexed: 12/31/2022]
Abstract
Background A label of penicillin allergy is held by 6-10% of the general population and 15-20% of inpatients. > 90% of these labels are found to be spurious after formal allergy assessment. Carrying an unnecessary label of penicillin allergy is not benign. Such patients may receive second line, more expensive antibiotics, representing a significant impediment to antimicrobial stewardship. Aim of the review To (a) Explain the burden of spurious penicillin allergy, and evaluate the safety of direct oral penicillin challenge in 'low risk' patients (b) appraise the place for a clinical pharmacist-led penicillin allergy de-labelling programme. Method Narrative review. Search engines: PubMed, Google Scholar and Cochrane reviews. Search criteria: English language; search terms: penicillin allergy, antimicrobial stewardship, antimicrobial resistance, clostridium difficile, vancomycin resistant enterococci, risk stratification, clinical pharmacist and direct oral provocation test Results Penicillin allergy labels are associated with: longer hospital stay, higher readmission rates, enhanced risk of surgical site infections, risk of Clostridioides difficile infection and Methicillin resistant Staphylococcus aureus infection, a delay in the first dose of an antibiotic in sepsis and higher healthcare costs. A direct oral penicillin challenge in 'low risk' patients has proven to be safe. Discussion Recent studies including those led by a clinical pharmacist have demonstrated safety of a direct oral penicillin challenge in 'low risk' patients. This intervention needs validation within individual health services. Conclusion Direct oral penicillin challenge reduces the adverse impact of spurious penicillin allergy. A pharmacist-led penicillin allergy de-labelling program needs further validation in prospective multi-centre studies.
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Affiliation(s)
- Rashmeet Bhogal
- Department of Pharmacy, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B9 5SS, UK.
| | - Abid Hussain
- Birmingham Public Health Laboratory, National Infection Service, Public Health England, Birmingham, UK
| | - Ariyur Balaji
- Department of Acute Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - William H Bermingham
- Department of Allergy and Immunology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - John F Marriott
- Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Mamidipudi T Krishna
- Department of Allergy and Immunology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Immunology & Immunotherapy, University of Birmingham, Birmingham, UK
- Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
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Simó S, Velasco-Arnaiz E, Ríos-Barnés M, López-Ramos MG, Monsonís M, Urrea-Ayala M, Jordan I, Casadevall-Llandrich R, Ormazábal-Kirchner D, Cuadras-Pallejà D, Tarrado X, Prat J, Sánchez E, Noguera-Julian A, Fortuny C. Effects of a Paediatric Antimicrobial Stewardship Program on Antimicrobial Use and Quality of Prescriptions in Patients with Appendix-Related Intraabdominal Infections. Antibiotics (Basel) 2020; 10:antibiotics10010005. [PMID: 33374676 PMCID: PMC7822420 DOI: 10.3390/antibiotics10010005] [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: 11/27/2020] [Revised: 12/18/2020] [Accepted: 12/21/2020] [Indexed: 11/16/2022] Open
Abstract
The effectiveness of antimicrobial stewardship programs (ASP) in reducing antimicrobial use (AU) in children has been proved. Many interventions have been described suitable for different institution sizes, priorities, and patients, with surgical wards being one of the areas that may benefit the most. We aimed to describe the results on AU and length of stay (LOS) in a pre-post study during the three years before (2014–2016) and the three years after (2017–2019) implementation of an ASP based on postprescription review with feedback in children and adolescents admitted for appendix-related intraabdominal infections (AR-IAI) in a European Referral Paediatric University Hospital. In the postintervention period, the quality of prescriptions (QP) was also evaluated. Overall, 2021 AR-IAIs admissions were included. Global AU, measured both as days of therapy/100 patient days (DOT/100PD) and length of therapy (LOT), and global LOS remained unchanged in the postintervention period. Phlegmonous appendicitis LOS (p = 0.003) and LOT (p < 0.001) significantly decreased, but not those of other AR-IAI diagnoses. The use of piperacillin–tazobactam decreased by 96% (p = 0.044), with no rebound in the use of other Gram-negative broad-spectrum antimicrobials. A quasisignificant (p = 0.052) increase in QP was observed upon ASP implementation. Readmission and case fatality rates remained stable. ASP interventions were safe, and they reduced LOS and LOT of phlegmonous appendicitis and the use of selected broad-spectrum antimicrobials, while increasing QP in children with AR-IAI.
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Affiliation(s)
- Sílvia Simó
- Infectious Diseases and Systemic Inflammatory Response in Paediatrics, Infectious Diseases Unit, Department of Paediatrics, Sant Joan de Déu Hospital Research Foundation, 08950 Barcelona, Spain; (S.S.); (E.V.-A.); (M.R.-B.); (C.F.)
- Centre for Biomedical Network Research on Epidemiology and Public Health (CIBERESP), 28029 Madrid, Spain;
| | - Eneritz Velasco-Arnaiz
- Infectious Diseases and Systemic Inflammatory Response in Paediatrics, Infectious Diseases Unit, Department of Paediatrics, Sant Joan de Déu Hospital Research Foundation, 08950 Barcelona, Spain; (S.S.); (E.V.-A.); (M.R.-B.); (C.F.)
| | - María Ríos-Barnés
- Infectious Diseases and Systemic Inflammatory Response in Paediatrics, Infectious Diseases Unit, Department of Paediatrics, Sant Joan de Déu Hospital Research Foundation, 08950 Barcelona, Spain; (S.S.); (E.V.-A.); (M.R.-B.); (C.F.)
| | | | - Manuel Monsonís
- Clinical Microbiology Department, Sant Joan de Déu Hospital, 08950 Barcelona, Spain;
| | - Mireia Urrea-Ayala
- Patient Safety Area—Infection Control Unit, Sant Joan de Déu Hospital, 08950 Barcelona, Spain;
| | - Iolanda Jordan
- Centre for Biomedical Network Research on Epidemiology and Public Health (CIBERESP), 28029 Madrid, Spain;
- Pediatric Intensive Care Unit, Sant Joan de Déu Hospital, 08950 Barcelona, Spain
- Department of Paediatrics, University of Barcelona, 08007 Barcelona, Spain
| | | | | | | | - Xavier Tarrado
- Paediatric Surgery Department, Sant Joan de Déu Hospital, 08950 Barcelona, Spain; (X.T.); (J.P.)
| | - Jordi Prat
- Paediatric Surgery Department, Sant Joan de Déu Hospital, 08950 Barcelona, Spain; (X.T.); (J.P.)
| | - Emília Sánchez
- Blanquerna School of Health Science, Ramon Llull University, 08022 Barcelona, Spain;
| | - Antoni Noguera-Julian
- Infectious Diseases and Systemic Inflammatory Response in Paediatrics, Infectious Diseases Unit, Department of Paediatrics, Sant Joan de Déu Hospital Research Foundation, 08950 Barcelona, Spain; (S.S.); (E.V.-A.); (M.R.-B.); (C.F.)
- Centre for Biomedical Network Research on Epidemiology and Public Health (CIBERESP), 28029 Madrid, Spain;
- Statistics Department, Sant Joan de Déu Research Foundation, 08950 Barcelona, Spain;
- Translational Research Network in Paediatric Infectious Diseases (RITIP), 28009 Madrid, Spain
- Correspondence: ; Tel.: +34-932-804-000 (ext. 80063); Fax: +34-932-033-959
| | - Clàudia Fortuny
- Infectious Diseases and Systemic Inflammatory Response in Paediatrics, Infectious Diseases Unit, Department of Paediatrics, Sant Joan de Déu Hospital Research Foundation, 08950 Barcelona, Spain; (S.S.); (E.V.-A.); (M.R.-B.); (C.F.)
- Centre for Biomedical Network Research on Epidemiology and Public Health (CIBERESP), 28029 Madrid, Spain;
- Statistics Department, Sant Joan de Déu Research Foundation, 08950 Barcelona, Spain;
- Translational Research Network in Paediatric Infectious Diseases (RITIP), 28009 Madrid, Spain
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Ashiru-Oredope D, Budd EL, Doble A, Cramp E, Hendrick A, Hopkins S. Development and implementation of a national antimicrobial stewardship surveillance system, with open access data sharing. J Hosp Infect 2020; 107:16-22. [PMID: 33122043 DOI: 10.1016/j.jhin.2020.10.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 10/19/2020] [Accepted: 10/21/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Public Health England (PHE) developed an antimicrobial stewardship (AMS) surveillance system and conducted a national pilot to test the feasibility of centrally collecting data from AMS audits performed by NHS hospital trusts. The system was simplified, focusing on requirements of the NHS AMR CQUIN (Commissioning for Quality and Innovation; a financial incentive quality improvement scheme). AIM To present results and user feedback from the national pilot, and results from using the AMS surveillance system as part of the AMR CQUIN. METHODS An AMS surveillance system was developed and a national pilot conducted in which 33 NHS trusts submitted data and feedback on system utilization. The system was refined based on feedback and deployed nationally to collect AMS data for the 2016-17 AMR CQUIN. FINDINGS Most trusts participating in the pilot collected data on documentation of indication (90%). Fewer collected data on documenting review decisions at 48-72 h (36%). On average 83% of patients had an indication documented, whereas 71% had formal documentation of 48-72 h review. AMR CQUIN data were submitted by 88% of trusts for at least one quarter of 2016-17. Approximately 92% of prescriptions had an indication documented and 87.5% of prescriptions had evidence of review within 72 h; these increased by 7 and 10 percentage points respectively between the first and final quarters. CONCLUSION The AMS surveillance system allowed AMS audit data from NHS trusts in England to be collected centrally. PHE publishes these data openly online, on PHE Fingertips portal, a national public health data portal. The reported data highlight improvement in the percentage of antibiotic prescriptions with evidence of a documented review within 72 h.
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Affiliation(s)
- D Ashiru-Oredope
- HCAI & AMR Division, National Infection Service, Public Health England, London, UK.
| | - E L Budd
- HCAI & AMR Division, National Infection Service, Public Health England, London, UK
| | - A Doble
- HCAI & AMR Division, National Infection Service, Public Health England, London, UK
| | - E Cramp
- Patient Safety Team, NHS Improvement, London, UK(1)
| | - A Hendrick
- HCAI & AMR Division, National Infection Service, Public Health England, London, UK
| | - S Hopkins
- HCAI & AMR Division, National Infection Service, Public Health England, London, UK
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Høye S, Brænd AM, Spehar I. Quality improvement and antimicrobial stewardship in general practice - the role of the municipality chief medical officer. A qualitative study. Scand J Prim Health Care 2020; 38:352-359. [PMID: 32735152 PMCID: PMC7470114 DOI: 10.1080/02813432.2020.1794400] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
AIMS This study aimed to explore the conditions for the Municipal Chief Medical Officers' (MCMOs) involvement in quality improvement in general practice, specifically concerning antibiotic prescribing practices. METHODS This qualitative study consisted of semi-structured in-depth telephone interviews and group interviews with MCMOs (n = 12). The interview guide aimed to explore the MCMOs' views on their role and responsibilities regarding the quality of care in general practice. The data were analysed using systematic text condensation. RESULTS Three main themes were identified: 1) the relationship between the municipality and the general practitioner (GP), with the MCMO acting as an intermediary, 2) influencing the GPs' work and 3) antibiotic use and infection control. The MCMOs perceived themselves as liaisons between the municipalities and the GPs. They emphasized building trust, showing respect and sharing common values in their interactions with the GPs, upholding the GPs' professional autonomy. Working for quality improvement was considered a priority; however, MCMOs expressed a need for external support to establish a permanent quality improvement framework. The informants were positive about engaging in improving antibiotic prescribing practices because this combined the municipality's responsibilities for quality improvement and communicable disease control. CONCLUSIONS The MCMOs considered themselves as well-suited agents for quality improvement in general practice, as liaisons between the municipalities and the GPs. Quality improvement in general practice would benefit from a clearer structure in terms of the MCMOs' roles and responsibilities. Within communicable diseases control, the MCMOs have a clear mandate, which places antimicrobial stewardship initiatives in a favourable position amongst other areas of quality improvement.
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Affiliation(s)
- Sigurd Høye
- Antibiotic Centre for Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
- CONTACT Sigurd Høye Antibiotic Centre for Primary Care, Department of General Practice, Institute of Health and society, University of Oslo, P.b. 1130 Blindern, Oslo0318, Norway
| | - Anja Maria Brænd
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Ivan Spehar
- Department of Health Management and Health Economics, Institute of Health and Society, University of Oslo, Oslo, Norway
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Tattevin P, Levy Hara G, Toumi A, Enani M, Coombs G, Voss A, Wertheim H, Poda A, Daoud Z, Laxminarayan R, Nathwani D, Gould I. Advocacy for Increased International Efforts for Antimicrobial Stewardship Actions in Low-and Middle-Income Countries on Behalf of Alliance for the Prudent Use of Antimicrobials (APUA), Under the Auspices of the International Society of Antimicrobial Chemotherapy (ISAC). Front Med (Lausanne) 2020; 7:503. [PMID: 32984380 PMCID: PMC7479847 DOI: 10.3389/fmed.2020.00503] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 07/21/2020] [Indexed: 01/27/2023] Open
Abstract
Antimicrobial stewardship (AMS) is a set of coordinated strategies to improve the use of antimicrobials, to enhance patient outcomes, reduce antimicrobial resistance, and decrease unnecessary costs. The pioneer years of AMS were restricted to high-income countries (HIC), where overconsumption of antibiotics was associated with emergence of multidrug-resistant (MDR) bacteria. AMS in low- and middle-income countries (LMIC) is also necessary. However, programs effective in HIC may not perform as well in LMIC, because (i) While decreased consumption of antibiotics may be an appropriate target in overconsuming HIC, this may be dangerous in LMIC, where many patients die from the lack of access to antibiotics; (ii) although AMS programs in HIC can be designed and monitored through laboratory surveillance of resistance, surveillance programs are not available in many LMIC; (iii) the heterogeneity of health care systems implies that AMS programs must be carefully contextualized. Despite the need to individually tailor AMS programs in LMIC, international collaborations remain highly valuable, through the dissemination of high-quality documents and educational material, that may be shared, adapted where needed, and adopted worldwide. This process, facilitated by modern communication tools, combines many benefits, including: (i) saving time, a precious dimension for health care workers, by avoiding the duplication of similar works in different settings; (ii) taking advantage of colleagues skills, and initiatives, through open access to the work performed in other parts of the world; (iii) sharing experiences, so that we all learn from each others' successes and failures.
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Affiliation(s)
- Pierre Tattevin
- Infectious Diseases and Intensive Care Unit, Pontchaillou University Hospital Center, Rennes, France
| | - Gabriel Levy Hara
- Infectious Diseases Unit, Hospital Carlos G. Durand, Buenos Aires, Argentina
| | - Adnene Toumi
- Infectious Diseases Department, Monastir University Hospital, Monastir, Tunisia
| | - Mushira Enani
- Faculty of Medicine, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Geoffrey Coombs
- Antimicrobial Resistance and Infectious Diseases Research Laboratory, Murdoch University, Perth, WA, Australia
| | - Andreas Voss
- Department of Medical Microbiology and Infectious Diseases, Canisius-Wilhelmina Hospital, Nijmegen, Netherlands.,Radboudumc, Department of Medical Microbiology and Radboud Center for Infectious Diseases, Nijmegen, Netherlands
| | - Heiman Wertheim
- Radboudumc, Department of Medical Microbiology and Radboud Center for Infectious Diseases, Nijmegen, Netherlands
| | - Armel Poda
- Infectious Diseases Department, Sourô Sanou University Hospital, Bobo-Dioulasso, Burkina Faso
| | - Ziad Daoud
- Clinical Microbiology, Saint George Hospital-UMC and University of Balamand, Beirut, Lebanon
| | | | - Dilip Nathwani
- Ninewells Hospital and Medical School, Dundee, United Kingdom
| | - Ian Gould
- Aberdeen Royal Infirmary, Aberdeen, United Kingdom
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Anyanwu PE, Pouwels K, Walker A, Moore M, Majeed A, Hayhoe BWJ, Tonkin-Crine S, Borek A, Hopkins S, Mcleod M, Costelloe C. Investigating the mechanism of impact and differential effect of the Quality Premium scheme on antibiotic prescribing in England: a longitudinal study. BJGP Open 2020; 4:bjgpopen20X101052. [PMID: 32665235 PMCID: PMC7465585 DOI: 10.3399/bjgpopen20x101052] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 02/10/2020] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND In 2017, approximately 73% of antibiotics in England were prescribed from primary care practices. It has been estimated that 9%-23% of antibiotic prescriptions between 2013 and 2015 were inappropriate. Reducing antibiotic prescribing in primary care was included as one of the national priorities in a financial incentive scheme in 2015-2016. AIM To investigate whether the effects of the Quality Premium (QP), which provided performance-related financial incentives to clinical commissioning groups (CCGs), could be explained by practice characteristics that contribute to variations in antibiotic prescribing. DESIGN & SETTING Longitudinal monthly prescribing data were analysed for 6251 primary care practices in England from April 2014 to March 2016. METHOD Linear generalised estimating equations models were fitted, examining the effect of the 2015-2016 QP on the number of antibiotic items per specific therapeutic group age-sex related prescribing unit (STAR-PU) prescribed, adjusting for seasonality and months since implementation. Consistency of effects after further adjustment for variations in practice characteristics were also examined, including practice workforce, comorbidities prevalence, prescribing rates of non-antibiotic drugs, and deprivation. RESULTS Antibiotics prescribed in primary care practices in England reduced by -0.172 items per STAR-PU (95% confidence interval [CI] = -0.180 to -0.171) after 2015-2016 QP implementation, with slight increases in the months following April 2015 (+0.014 items per STAR-PU; 95% CI = +0.013 to +0.014). Adjusting the model for practice characteristics, the immediate and month-on-month effects following implementation remained consistent, with slight attenuation in immediate reduction from -0.172 to -0.166 items per STAR-PU. In subgroup analysis, the QP effect was significantly greater among the top 20% prescribing practices (interaction p<0.001). Practices with low workforce and those with higher diabetes prevalence had greater reductions in prescribing following 2015-2016 QP compared with other practices (interaction p<0.001). CONCLUSION In high-prescribing practices, those with low workforce and high diabetes prevalence had more reduction following the QP compared with other practices, highlighting the need for targeted support of these practices and appropriate resourcing of primary care.
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Affiliation(s)
- Philip Emeka Anyanwu
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Koen Pouwels
- Nuffield Department of Population Health, Health Economics Research Centre, University of Oxford, Oxford, UK
| | - Anne Walker
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- National Institute for Health Research (NIHR) Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
| | - Michael Moore
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, UK
| | - Azeem Majeed
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Benedict W J Hayhoe
- Primary Care and Public Health, Imperial College London School of Public Health, London, UK
| | - Sarah Tonkin-Crine
- National Institute for Health Research (NIHR) Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Aleksandra Borek
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Susan Hopkins
- Healthcare-Associated Infection and Antimicrobial Resistance Department, National Infection Service, Public Health England, London, UK
- Directorate of Infection, Royal Free London NHS Foundation Trust, London, UK
- Department of Infectious Disease, Imperial College London, London, UK
| | - Monsey Mcleod
- Pharmacy Department, Centre for Medication Safety and Service Quality, Imperial College London, London, UK
- NIHR Patient Safety Translational Research Centre, Imperial College London, London, UK
- NIHR Health Protection Research Unit in Healthcare-Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
| | - Céire Costelloe
- Department of Primary Care and Public Health, Imperial College London, London, UK
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Avent ML, Cosgrove SE, Price-Haywood EG, van Driel ML. Antimicrobial stewardship in the primary care setting: from dream to reality? BMC FAMILY PRACTICE 2020; 21:134. [PMID: 32641063 PMCID: PMC7346425 DOI: 10.1186/s12875-020-01191-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 06/15/2020] [Indexed: 12/03/2022]
Abstract
BACKGROUND Clinicians who work in primary care are potentially the most influential healthcare professionals to address the problem of antibiotic resistance because this is where most antibiotics are prescribed. Despite a number of evidence based interventions targeting the management of community infections, the inappropriate antibiotic prescribing rates remain high. DISCUSSION The question is how can appropriate prescribing of antibiotics through the use of Antimicrobial Stewardship (AMS) programs be successfully implemented in primary care. We discuss that a top-down approach utilising a combination of strategies to ensure the sustainable implementation and uptake of AMS interventions in the community is necessary to support clinicians and ensure a robust implementation of AMS in primary care. Specifically, we recommend a national accreditation standard linked to the framework of Core Elements of Outpatient Antibiotic Stewardship, supported by resources to fund the implementation of AMS interventions that are connected to quality improvement initiatives. This article debates how this can be achieved. The paper highlights that in order to support the sustainable uptake of AMS programs in primary care, an approach similar to the hospital and post-acute care settings needs to be adopted, utilising a combination of behavioural and regulatory processes supported by sustainable funding. Without these strategies the problem of inappropriate antibiotic prescribing will not be adequately addressed in the community and the successful implementation and uptake of AMS programs will remain a dream.
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Affiliation(s)
- M L Avent
- Statewide Antimicrobial Stewardship Program, Queensland Health, Brisbane, Australia.
- UQ Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, Australia.
| | - S E Cosgrove
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - E G Price-Haywood
- Ochsner Health System, Center for Outcomes and Health Services Research, New Orleans, Louisiana, USA
- Ochnser Clinical School, The University of Queensland, New Orleans, Louisiana, USA
| | - M L van Driel
- Primary Care Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, Australia
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Scobie A, Budd EL, Harris RJ, Hopkins S, Shetty N. Antimicrobial stewardship: an evaluation of structure and process and their association with antimicrobial prescribing in NHS hospitals in England. J Antimicrob Chemother 2020; 74:1143-1152. [PMID: 30649321 DOI: 10.1093/jac/dky538] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 10/30/2018] [Accepted: 11/26/2018] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Rigorous antimicrobial stewardship programmes (ASPs) are an essential strategy against antimicrobial resistance. OBJECTIVES To evaluate and score ASPs in acute English NHS hospitals and determine association of ASP scores with antimicrobial prescribing. METHODS ASP structure and process were evaluated through an online survey in 148/152 acute hospitals in 2017. Scores were assigned to quality indicators based on resource- and labour-intensiveness, and their association with total and modified WHO-categorized 'Access', 'Watch' and 'Reserve' (AwaRe) prescribing was analysed. RESULTS The survey response rate was 97% with 78% of trusts submitting antimicrobial prescribing data. Over 80% of ASPs contained stewardship teams, policies and access to outpatient parenteral antimicrobial therapy, whilst less than 50% scored well for leadership or funding. High process performance was observed for antimicrobial pre-authorization, prescribing review and feedback, restricted susceptibility reporting, antimicrobial consumption monitoring, adherence to guidelines and junior doctor training. Low process attainment included education of senior prescribers and lack of resistance surveillance data distribution. Between 2016 and 2017, there was no difference in total trust prescribing (P = 0.117) although carbapenem prescribing fell (incidence rate ratio = 0.93, 95% CI 0.88-0.98) in non-teaching hospitals; 'Watch' prescribing also increased for specialist hospitals (OR = 1.10, 95% CI 1.01-1.20), as did 'Reserve' category prescribing in teaching (OR = 1.58, 95% CI 1.23-3.02) and specialist hospitals (OR = 3.09, 95% CI 2.02-4.74). A high process score was associated with lower 'Reserve' prescribing (OR = 0.82, 95% CI 0.67-1.01). CONCLUSIONS All responding trusts had established ASPs. The association of a scoring system with total and 'AWaRe' prescribing to assess effectiveness of ASPs merits further study.
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Affiliation(s)
- Antonia Scobie
- Reference Microbiology, National Infection Service, Public Health England, 61 Colindale Avenue, London, UK
| | - Emma L Budd
- Healthcare-Associated Infection & Antimicrobial Resistance Division, National Infection Service, Public Health England, 61 Colindale Avenue, London, UK
| | - Ross J Harris
- Statistics, Modelling and Economics Department, National Infection Service, Public Health England, 61 Colindale Avenue, London, UK
| | - Susan Hopkins
- Healthcare-Associated Infection & Antimicrobial Resistance Division, National Infection Service, Public Health England, 61 Colindale Avenue, London, UK
| | - Nandini Shetty
- Reference Microbiology, National Infection Service, Public Health England, 61 Colindale Avenue, London, UK
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Van Hecke O, Coetzee R. Establishing a pharmacist-prescriber partnership in publicly funded primary healthcare clinics to optimise antibiotic prescribing in the Western Cape: An exploratory study. S Afr Fam Pract (2004) 2020; 62:e1-e4. [PMID: 32633996 PMCID: PMC8378124 DOI: 10.4102/safp.v62i1.5090] [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: 01/21/2020] [Revised: 04/18/2020] [Accepted: 04/20/2020] [Indexed: 12/02/2022] Open
Abstract
Background Promoting evidence-based antibiotic prescribing through successful antimicrobial stewardship (AMS) programmes is critical to preserving the effectiveness of antibiotics for common infections in primary care. This requires a coordinated multidisciplinary effort. Such pharmacist–prescriber partnerships have been effective in high-income countries (HICs). Yet, evidence generated in such countries is not always applicable because of different social determinants of health. Methods A multidisciplinary workshop was conducted with pharmacists and clinicians (doctors, nurses) on community-based antibiotic stewardship, the purpose of which was to explore how and where such partnerships might work in publicly funded primary care clinics in the greater Cape Metro region. Results Participants perceived that promoting effective AMS was a priority for South African primary healthcare. However, it was clear that there are many hurdles to overcome working in settings that are relatively resource-poor. Prescribing guidelines needed to be harmonised. Participants felt that staff training on the principles of AMS should be mandatory. Research was urgently needed to better understand their community’s understanding of antibiotic use and AMS, and to champion outreach projects in the community. Conclusion Important stakeholder perspectives in the community were highlighted to promote a multidisciplinary approach to AMS initiatives in primary care. These will need to be addressed to optimise antibiotic prescribing in the community.
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Affiliation(s)
- Oliver Van Hecke
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford.
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Label-Free Electrochemical Microfluidic Chip for the Antimicrobial Susceptibility Testing. Antibiotics (Basel) 2020; 9:antibiotics9060348. [PMID: 32575678 PMCID: PMC7344617 DOI: 10.3390/antibiotics9060348] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 06/17/2020] [Accepted: 06/17/2020] [Indexed: 01/15/2023] Open
Abstract
The emergence and spread of antibiotic-resistant bacteria is a global threat to human health. An accurate antibiotic susceptibility test (AST) before initiating the treatment is paramount in the treatment and bacterial resistance control. However, the current AST methods either are complex, use chemical and biological labels, lack multiplexing, are expensive, or are too slow to be used for routine screening. The primary objective of the current study is to develop an automated electrochemical microfluidic chip (EMC) for simple and rapid AST. The microfluidic channels and gold microelectrodes were designed for the automation of antibiotic mixing and distribution in multiple test chambers and for electrical signal measurements. The designed chip was tested for AST with E. coli samples, and the results were compared with conventional broth microdilution. The presented EMC provided rapid bacterial count and AST in 170 and 150 min, respectively, while the conventional broth microdilution evaluates in 450 and 240 min, respectively. The rapid AST capability of the EMC was further demonstrated with the artificial urine samples, and the results were obtained in 270 min, which was 90 min faster than the broth microdilution method. Additionally, the minimum inhibitory concentration (MIC) was evaluated on the EMC and compared with the results from an AlamarBlue assay. The experimental results indicate the sensitivity of the chip, minimum loss of antibiotics, and eventually, reduction in the evolution of antibiotic resistance. Cumulatively, we have developed an automated, label-free, economical, rapid, robust, and user-friendly EMC for the evaluation of AST in urine samples.
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Hempel S, O’Hanlon C, Lim YW, Danz M, Larkin J, Rubenstein L. Spread tools: a systematic review of components, uptake, and effectiveness of quality improvement toolkits. Implement Sci 2019; 14:83. [PMID: 31426825 PMCID: PMC6701087 DOI: 10.1186/s13012-019-0929-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 07/26/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The objective was to conduct a systematic review of toolkit evaluations intended to spread interventions to improve healthcare quality. We aimed to determine the components, uptake, and effectiveness of publicly available toolkits. METHODS We searched PubMed, CINAHL, and the Web of Science from 2005 to May 2018 for evaluations of publicly available toolkits, used a forward search of known toolkits, screened references, and contacted topic experts. Two independent reviewers screened publications for inclusion. One reviewer abstracted data and appraised the studies, checked by a second reviewer; reviewers resolved disagreements through discussion. Findings, summarized in comprehensive evidence tables and narrative synthesis addressed the uptake and utility, procedural and organizational outcomes, provider outcomes, and patient outcomes. RESULTS In total, 77 studies evaluating 72 toolkits met inclusion criteria. Toolkits addressed a variety of quality improvement approaches and focused on clinical topics such as weight management, fall prevention, vaccination, hospital-acquired infections, pain management, and patient safety. Most toolkits included introductory and implementation material (e.g., research summaries) and healthcare provider tools (e.g., care plans), and two-thirds included material for patients (e.g., information leaflets). Pre-post studies were most common (55%); 10% were single hospital evaluations and the number of participating staff ranged from 17 to 704. Uptake data were limited and toolkit uptake was highly variable. Studies generally indicated high satisfaction with toolkits, but the perceived usefulness of individual tools varied. Across studies, 57% reported on adherence to clinical procedures and toolkit effects were positive. Provider data were reported in 40% of studies but were primarily self-reported changes. Only 29% reported patient data and, overall, results from robust study designs are missing from the evidence base. CONCLUSIONS The review documents publicly available toolkits and their components. Available uptake data are limited but indicate variability. High satisfaction with toolkits can be achieved but the usefulness of individual tools may vary. The existing evidence base on the effectiveness of toolkits remains limited. While emerging evidence indicates positive effects on clinical processes, more research on toolkit value and what affects it is needed, including linking toolkits to objective provider behavior measures and patient outcomes. TRIAL REGISTRATION PROSPERO registration number: PROSPERO 2014: CRD42014013930 .
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Affiliation(s)
- Susanne Hempel
- Southern California Evidence-based Practice Center, RAND Corporation, Santa Monica, USA
- Southern California Evidence Review Center, University of Southern California, Los Angeles, USA
| | | | - Yee Wei Lim
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Margie Danz
- Southern California Evidence-based Practice Center, RAND Corporation, Santa Monica, USA
- Southern California Evidence Review Center, University of Southern California, Los Angeles, USA
| | - Jody Larkin
- Knowledge Services, RAND Corporation, Santa Monica, USA
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Conlon-Bingham GM, Aldeyab M, Scott M, Kearney MP, Farren D, Gilmore F, McElnay J. Effects of Antibiotic Cycling Policy on Incidence of Healthcare-Associated MRSA and Clostridioides difficile Infection in Secondary Healthcare Settings. Emerg Infect Dis 2019; 25:52-62. [PMID: 30561306 PMCID: PMC6302607 DOI: 10.3201/eid2501.180111] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
This quasi-experimental study investigated the effect of an antibiotic cycling policy based on time-series analysis of epidemiologic data, which identified antimicrobial drugs and time periods for restriction. Cyclical restrictions of amoxicillin/clavulanic acid, piperacillin/tazobactam, and clarithromycin were undertaken over a 2-year period in the intervention hospital. We used segmented regression analysis to compare the effect on the incidence of healthcare-associated Clostridioides difficile infection (HA-CDI), healthcare-associated methicillin-resistant Staphylococcus aureus (HA-MRSA), and new extended-spectrum β-lactamase (ESBL) isolates and on changes in resistance patterns of the HA-MRSA and ESBL organisms between the intervention and control hospitals. HA-CDI incidence did not change. HA-MRSA incidence increased significantly in the intervention hospital. The resistance of new ESBL isolates to amoxicillin/clavulanic acid and piperacillin/tazobactam decreased significantly in the intervention hospital; however, resistance to piperacillin/tazobactam increased after a return to the standard policy. The results question the value of antibiotic cycling to antibiotic stewardship.
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32
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Bradley DT, Allen SE, Quinn H, Bradley B, Dolan M. Social norm feedback reduces primary care antibiotic prescribing in a regression discontinuity study. J Antimicrob Chemother 2019; 74:2797-2802. [DOI: 10.1093/jac/dkz222] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Revised: 04/24/2019] [Accepted: 04/26/2019] [Indexed: 01/04/2023] Open
Abstract
Abstract
Background
Reducing antibiotic prescribing is a priority for health authorities responsible for preventing antimicrobial resistance. Northern Ireland has high rates of antimicrobial use. We implemented a social norm feedback intervention and evaluated its impact.
Objectives
To estimate the size and duration of the effect of a social norm feedback letter to GPs who worked in the 20% of practices with the highest antimicrobial prescribing.
Methods
The letter was sent in October 2017 to 221 GPs in 67 practices. To assess the effect of the intervention, we used a sharp non-parametric regression discontinuity (RD) design, with prescribing rates in the four calendar quarters following the intervention as the outcome variables.
Results
In the quarter following the intervention (October to December 2017) there was a change of −25.7 (95% CI = −42.5 to −8.8, P = 0.0028) antibiotic items per 1000 Specific Therapeutic group Age-sex Related Prescribing Units (STAR-PU). At 1 year, the coefficient was −58.7 (95% CI = −116.7 to −0.7, P = 0.047) antibiotic items per 1000 STAR-PU. The greatest change occurred soon after the intervention. Approximately 18900 fewer antibiotic items were prescribed than if the intervention had not been made (1% of Northern Ireland’s annual primary care antibiotic prescribing).
Conclusions
A social norm feedback intervention reduced antibiotic prescribing in the intervention practices. The diminishing effect over time suggests the need for more frequent feedback. The RD method allowed measurement of the effectiveness of an intervention that was delivered as part of normal business, without a randomized trial.
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Affiliation(s)
- Declan T Bradley
- Centre for Public Health, Institute of Clinical Sciences, Block A, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Royal Victoria Hospital, Grosvenor Road, Belfast, UK
- Public Health Agency, 12–22 Linenhall Street, Belfast, UK
| | - Sarah E Allen
- Public Sector Innovation Lab, Department of Finance, Clare House, 303 Airport Road, Belfast, UK
- Northern Ireland Statistics and Research Agency, Belfast, UK
| | - Helen Quinn
- Health and Social Care Board, 12–22 Linenhall Street, Belfast, UK
| | - Brenda Bradley
- Health and Social Care Board, 12–22 Linenhall Street, Belfast, UK
| | - Matthew Dolan
- Health and Social Care Board, 12–22 Linenhall Street, Belfast, UK
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33
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Weier N, Tebano G, Thilly N, Demoré B, Pulcini C, Zaidi STR. Pharmacist participation in antimicrobial stewardship in Australian and French hospitals: a cross-sectional nationwide survey. J Antimicrob Chemother 2019; 73:804-813. [PMID: 29237051 DOI: 10.1093/jac/dkx435] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 10/30/2017] [Indexed: 12/29/2022] Open
Abstract
Background Hospital pharmacists are an integral part of antimicrobial stewardship (AMS) programmes globally. Currently, little is known as to how hospital pharmacists see their role and involvement within the AMS framework. Objectives To assess the current level of involvement of Australian and French hospital pharmacists in AMS programmes and identify barriers limiting their involvement in AMS. Methods Hospital pharmacists throughout Australia and France were invited to participate in a nationwide online survey throughout March-May 2016. The survey was promoted through the national hospital pharmacists' association in Australia, while a stratified sampling method was used in France to invite pharmacists working in a variety of hospital settings. Results Invitations to participate in this survey were sent to 334 Australian pharmacists and 482 French pharmacists. Responses from 133 Australian and 126 French pharmacists were included for analysis. A total of 78.4% (203/259) of pharmacists reported the presence of an AMS programme. Pharmacists were most likely to be involved in AMS through assessing total antibiotic consumption and participating in AMS committee meetings. Barriers to participating in AMS included a lack of time and substantial non-clinical activities limiting involvement in AMS. Differences in responses were found between the two countries. Conclusions While the majority of pharmacists reported the presence of an AMS programme, multiple barriers to participation were identified by pharmacists in both countries. Further research should consider how to overcome the identified barriers to optimize the involvement of pharmacists in AMS.
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Affiliation(s)
- Naomi Weier
- Division of Pharmacy, School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | | | - Nathalie Thilly
- Université de Lorraine, EA 4360 APEMAC, Nancy, France.,Centre Hospitalier Régional Universitaire de Nancy, Plateforme d'Aide à la Recherche Clinique, Nancy, France
| | - Béatrice Demoré
- Centre Hospitalier Régional Universitaire de Nancy, Pharmacie Brabois, Nancy, France.,UMR 7565, SRSMC, CNRS-Lorraine University, Faculté de Pharmacie, Rue Albert Lebrun, Nancy, France
| | - Céline Pulcini
- Université de Lorraine, EA 4360 APEMAC, Nancy, France.,Centre Hospitalier Régional Universitaire de Nancy, Service de Maladies Infectieuses et Tropicales, Nancy, France
| | - Syed Tabish R Zaidi
- Division of Pharmacy, School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
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34
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Heard KL, Hughes S, Mughal N, Azadian BS, Moore LSP. Evaluating the impact of the ICNET® clinical decision support system for antimicrobial stewardship. Antimicrob Resist Infect Control 2019; 8:51. [PMID: 30886704 PMCID: PMC6404285 DOI: 10.1186/s13756-019-0496-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 02/13/2019] [Indexed: 01/21/2023] Open
Abstract
Background Antimicrobial resistance (AMR) is an ecological and economic crisis and stewardship of available antimicrobials is required. Electronic prescribing, where available, enables auditing of practice, yet in order to be efficient and effective in addressing inappropriate antimicrobial prescribing, better use of current and new technological interventions is needed. This retrospective observational evaluation looked at the impact of a commercial clinical decision support system (CDSS) on the workflow of an established antimicrobial stewardship (AMS) team. Material/methods Clinical, workflow, and pharmaceutical data from 3 months post implementation of CDSS were collated, and compared to the same 3 month periods in preceding years. The evaluation considered total interventions made, the types of intervention made, impact of said interventions, and time spent executing interventions. All antimicrobial data were adjusted for total daily defined doses (DDD) of intravenous antimicrobials. Results Productivity: In the 3 month evaluation period (Jun-Aug 2016) a total of 264 case reviews resulting in 298 AMS interventions were made. Compared to preceding years where 138 and 169 interventions were made (2013 and 2014 respectively). In 2013 49% of interventions were stopping medication and 30% change of therapy based on cultures and sensitivities compared to 25 and 17% in 2016. In contrast to previous years’, the CDSS instead enabled a greater number of dose/drug optimisation (13%), escalation of antimicrobials (12%) and intravenous (IV) to oral switch (11%) interventions. Patient Identification: Despite increased patient numbers post-CDSS, on average 46 min per day was spent compiling a patient list for review, compared to 59 min in 2014. The use of CDSS facilitated 15 interventions/1000DDD, compared to pre-intervention (9.4/1000DDD in 2013; 11.5/1000DDD in 2014). Conclusions Initial evaluation of the impact of this CDSS on AMS at the organisation has demonstrated effectiveness in terms of case finding, AMS team productivity, and workflow auditing. More importantly, patient infection management has been optimised with a shift in the emphasis of AMS interventions. It has contributed to the success of the healthcare provider achieving nationally set remunerated AMS targets.
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Affiliation(s)
- Katie L Heard
- 1Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH UK
| | - Stephen Hughes
- 1Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH UK
| | - Nabeela Mughal
- 1Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH UK.,North West London Pathology, Fulham Palace Road, London, W6 8RF UK
| | - Berge S Azadian
- 1Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH UK
| | - Luke S P Moore
- 1Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH UK.,North West London Pathology, Fulham Palace Road, London, W6 8RF UK.,3National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, Du Cane Road, London, W12 0NN UK
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35
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Johnston DN, Keshtkar F, Campbell W. The effect of re-audit and education on antibiotic prescribing practice at Causeway Hospital, Northern Ireland. Ir J Med Sci 2019; 188:1149-1153. [PMID: 30810949 DOI: 10.1007/s11845-019-01995-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 02/16/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Antimicrobial resistance is a growing global problem. There has been increasing emphasis on promoting antimicrobial stewardship. Accurate completion of antibiotic prescriptions, such as documentation of clinical indication and a stop/review date, helps promote antimicrobial stewardship. AIMS To investigate the impact of educational interventions on the completeness of antibiotic prescriptions at Causeway Hospital surgical unit. METHODS Inpatient drug prescription charts were audited to monitor the completeness of antibiotic prescriptions on the surgical unit. Two educational interventions were implemented, with a subsequent prospective re-audit carried out. RESULTS The completion of (1) "Stop date/Review date", (2) "What infection are you treating?", (3) "Cultures sent?", (4) "Printed name", (5) "Professional number", and (6) "Bleep number" fields within the inpatient drug charts increased noticeably in the re-audit. A paired t test, comparing all of the initial audit completion proportions with the re-audit completion proportions, demonstrated a statistically significant improvement (p < 0.05). CONCLUSIONS Educational interventions led to an improvement in the completeness of antibiotic prescriptions. This highlights the important role that continued audit and education play in the promotion of antimicrobial stewardship.
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Affiliation(s)
- David N Johnston
- Department of Surgery, Northern HSC Trust, Causeway Hospital, 4 Newbridge Road, Coleraine, BT52 1HS, Northern Ireland.
| | - Fatemeh Keshtkar
- Department of Surgery, Northern HSC Trust, Causeway Hospital, 4 Newbridge Road, Coleraine, BT52 1HS, Northern Ireland
| | - William Campbell
- Department of Surgery, Northern HSC Trust, Causeway Hospital, 4 Newbridge Road, Coleraine, BT52 1HS, Northern Ireland
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Sandoe JAT, Saeed K, Guleri A, Hand KS, Dillon R, Allen M, Mayes A, Glen F, Gonzalez-Ruiz A. Opportunities for antimicrobial stewardship in patients with acute bacterial skin and skin structure infections who are unsuitable for beta-lactam antibiotics: a multicenter prospective observational study. Ther Adv Infect Dis 2019; 6:2049936118823655. [PMID: 30783523 PMCID: PMC6365991 DOI: 10.1177/2049936118823655] [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: 08/03/2018] [Accepted: 12/14/2018] [Indexed: 11/16/2022] Open
Abstract
Purpose: The objective of this prospective, observational study was to describe the treatment, severity assessment and healthcare resources required for management of patients with acute bacterial skin and skin structure infections who were unsuitable for beta-lactam antibiotic treatments. Methods: Patients were enrolled across five secondary care National Health Service hospitals. Eligible patients had a diagnosis of acute bacterial skin and skin structure infection and were considered unsuitable for beta-lactam antibiotics (e.g. confirmed/suspected methicillin-resistant Staphylococcus aureus, beta-lactam allergy). Data regarding diagnosis, severity of the infection, antibiotic treatment and patient management were collected. Results: 145 patients with acute bacterial skin and skin structure infection were included; 79% (n = 115) patients received greater than two antibiotic regimens; median length of the first antibiotic regimen was 2 days (interquartile range of 1–5); median time to switch from intravenous to oral antibiotics was 4 days (interquartile range of 3–8, n = 72/107); 25% (n = 10/40) patients with Eron class 1 infection had systemic inflammatory response syndrome, suggesting they were misclassified. A higher proportion of patients with systemic inflammatory response syndrome received treatment in an inpatient setting, and their length of stay was prolonged in comparison with patients without systemic inflammatory response syndrome. Conclusion: There exists an urgent need for more focused antimicrobial stewardship strategies and tools for standardised clinical assessment of acute bacterial skin and skin structure infection severity in patients who are unsuitable for beta-lactam antibiotics. This will lead to optimised antimicrobial treatment strategies and ensure effective healthcare resource utilisation.
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Affiliation(s)
| | - Kordo Saeed
- Hampshire Hospitals NHS Foundation Trust and University of Southampton, Southampton, UK
| | - Achyut Guleri
- Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - Kieran S Hand
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Ryan Dillon
- Merck Sharp & Dohme UK Ltd. (MSD), Hoddesdon, UK
| | - Mike Allen
- Merck Sharp & Dohme UK Ltd. (MSD), Hoddesdon, UK
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37
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Ashiru-Oredope D, Doble A, Akpan MR, Hansraj S, Shebl NA, Ahmad R, Hopkins S. Antimicrobial Stewardship Programmes in Community Healthcare Organisations in England: A Cross-Sectional Survey to Assess Implementation of Programmes and National Toolkits. Antibiotics (Basel) 2018; 7:E97. [PMID: 30405004 PMCID: PMC6316239 DOI: 10.3390/antibiotics7040097] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 10/29/2018] [Accepted: 10/31/2018] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE The aim of this study was to assess antimicrobial stewardship activities in Community Healthcare Organisations (CHOs) with focus on the implementation of the two national antimicrobial stewardship toolkits, TARGET (Treat Antibiotics Responsibly, Guidance, Education, Tools) and SSTF (Start Smart, then Focus). The study utilised a web-based survey comprising 34 questions concerning antimicrobial policies and awareness and implementation of antimicrobial stewardship toolkits. This was distributed to pharmacy teams in all 26 CHOs in England. Twenty CHOs (77%) responded. An antimicrobial stewardship (AMS) committee was active in 50% of CHOs; 25% employed a substantive pharmacist post and 70% had a local antibiotic policy. Fourteen of the responding CHOs were aware of both AMS toolkits, five organisations were aware of either SSTF or TARGET, and one organisation was not aware of either toolkit. Of the organisations aware of SSTF and TARGET, eight had formally reviewed both toolkits, though three had not reviewed either. Less than half of the respondents had developed local action plans for either toolkit. National guidance in England has focused attention on initiatives to improve AMS implementation in primary and secondary care; more work is required to embed AMS activities and the implementation of national AMS toolkit recommendations within CHOs.
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Affiliation(s)
| | - Anne Doble
- HCAI & AMR Division, Public Health England, London NW9 5EQ, UK.
| | - Mary Richard Akpan
- Department of Clinical and Pharmaceutical Sciences, University of Hertfordshire, Hatfield AL10 9AB, UK.
| | - Sejal Hansraj
- HCAI & AMR Division, Public Health England, London NW9 5EQ, UK.
| | - Nada Atef Shebl
- Department of Clinical and Pharmaceutical Sciences, University of Hertfordshire, Hatfield AL10 9AB, UK.
| | - Raheelah Ahmad
- NIHR Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance at Imperial College London, Hammersmith Campus, Du Cane Road, London W12 0NN, UK.
| | - Susan Hopkins
- HCAI & AMR Division, Public Health England, London NW9 5EQ, UK.
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Giuliano CA, Binienda J, Kale-Pradhan PB, Fakih MG. "I Never Would Have Caught That Before": Pharmacist Perceptions of Using Clinical Decision Support for Antimicrobial Stewardship in the United States. QUALITATIVE HEALTH RESEARCH 2018; 28:745-755. [PMID: 29334865 DOI: 10.1177/1049732317750863] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
To systematically improve the appropriateness of antibiotic prescribing, antimicrobial stewardship programs have been developed. There is a paucity of literature examining how pharmacists perform antimicrobial stewardship using a clinical decision support system in a hospital setting. The purpose of this qualitative study was to develop a model exploring how pharmacists perform antimicrobial stewardship to identify areas for programmatic improvement. Semistructured interviews were conducted across a health care system until saturation of themes was reached. Pharmacists identified that self-efficacy and time were vital for antimicrobial stewardship to be performed, while culture of the hospital and attitude facilitated the process of stewardship. Antimicrobial stewardship programs using clinical decision support tools should ensure pharmacists have adequate time to address rules, provide easy-to-use resources and training to support self-efficacy, and engage influential physicians to support a culture of collaboration.
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Affiliation(s)
- Christopher A Giuliano
- 1 Wayne State University, Detroit, Michigan, USA
- 2 Ascension St. John Hospital, Detroit, Michigan, USA
| | | | - Pramodini B Kale-Pradhan
- 1 Wayne State University, Detroit, Michigan, USA
- 2 Ascension St. John Hospital, Detroit, Michigan, USA
| | - Mohamad G Fakih
- 1 Wayne State University, Detroit, Michigan, USA
- 2 Ascension St. John Hospital, Detroit, Michigan, USA
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Papoutsi C, Mattick K, Pearson M, Brennan N, Briscoe S, Wong G. Interventions to improve antimicrobial prescribing of doctors in training (IMPACT): a realist review. HEALTH SERVICES AND DELIVERY RESEARCH 2018. [DOI: 10.3310/hsdr06100] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundInterventions to improve the antimicrobial prescribing practices of doctors have been implemented widely to curtail the emergence and spread of antimicrobial resistance, but have been met with varying levels of success.ObjectivesThis study aimed to generate an in-depth understanding of how antimicrobial prescribing interventions ‘work’ (or do not work) for doctors in training by taking into account the wider context in which prescribing decisions are enacted.DesignThe review followed a realist approach to evidence synthesis, which uses an interpretive, theory-driven analysis of qualitative, quantitative and mixed-methods data from relevant studies.SettingPrimary and secondary care.ParticipantsNot applicable.InterventionsStudies related to antimicrobial prescribing for doctors in training.Main outcome measuresNot applicable.Data sourcesEMBASE (via Ovid), MEDLINE (via Ovid), MEDLINE In-Process & Other Non-Indexed Citations (via Ovid), PsycINFO (via Ovid), Web of Science core collection limited to Science Citation Index Expanded (SCIE) and Conference Proceedings Citation Index – Science (CPCI-S) (via Thomson Reuters), Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, the Health Technology Assessment (HTA) database (all via The Cochrane Library), Applied Social Sciences Index and Abstracts (ASSIA) (via ProQuest), Google Scholar (Google Inc., Mountain View, CA, USA) and expert recommendations.Review methodsClearly bounded searches of electronic databases were supplemented by citation tracking and grey literature. Following quality standards for realist reviews, the retrieved articles were systematically screened and iteratively analysed to develop theoretically driven explanations. A programme theory was produced with input from a stakeholder group consisting of practitioners and patient representatives.ResultsA total of 131 articles were included. The overarching programme theory developed from the analysis of these articles explains how and why doctors in training decide to passively comply with or actively follow (1) seniors’ prescribing habits, (2) the way seniors take into account prescribing aids and seek the views of other health professionals and (3) the way seniors negotiate patient expectations. The programme theory also explains what drives willingness or reluctance to ask questions about antimicrobial prescribing or to challenge the decisions made by seniors. The review outlines how these outcomes result from complex inter-relationships between the contexts of practice doctors in training are embedded in (hierarchical relationships, powerful prescribing norms, unclear roles and responsibilities, implicit expectations about knowledge levels and application in practice) and the mechanisms triggered in these contexts (fear of criticism and individual responsibility, reputation management, position in the clinical team and appearing competent). Drawing on these findings, we set out explicit recommendations for optimal tailoring, design and implementation of antimicrobial prescribing interventions targeted at doctors in training.LimitationsMost articles included in the review discussed hospital-based, rather than primary, care. In cases when few data were available to fully capture all the nuances between context, mechanisms and outcomes, we have been explicit about the strength of our arguments.ConclusionsThis review contributes to our understanding of how antimicrobial prescribing interventions for doctors in training can be better embedded in the hierarchical and interprofessional dynamics of different health-care settings.Future workMore work is required to understand how interprofessional support for doctors in training can contribute to appropriate prescribing in the context of hierarchical dynamics.Study registrationThis study is registered as PROSPERO CRD42015017802.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Chrysanthi Papoutsi
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Karen Mattick
- Centre for Research in Professional Learning, University of Exeter, Exeter, UK
| | - Mark Pearson
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care for the South West Peninsula, Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - Nicola Brennan
- Collaboration for the Advancement of Medical Education Research and Assessment, Peninsula Schools of Medicine and Dentistry, Plymouth University, Plymouth, UK
| | - Simon Briscoe
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care for the South West Peninsula, Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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40
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Avent ML, Fejzic J, van Driel ML. An underutilised resource for Antimicrobial Stewardship: a 'snapshot' of the community pharmacists' role in delayed or 'wait and see' antibiotic prescribing. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2018; 26:373-375. [PMID: 29318696 DOI: 10.1111/ijpp.12431] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 12/08/2017] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Various strategies have been implemented in primary care to address the inappropriate use of antibiotics, with varying degrees of success. One such intervention is delayed or 'wait and see' prescribing, where the prescriber indicates to wait a few days before dispensing the antibiotic. The aim of this study was to explore community pharmacists' perceptions and practice experiences with delayed antibiotic prescribing. METHODS An online survey was advertised in two professional pharmacy organisations' e-newsletters for community and internship pharmacists in Queensland, Australia, from January to April 2016. KEY FINDINGS We received 120 responses. 103 (86%) worked in a community pharmacy. Sixty per cent of the respondents would not dispense the delayed antibiotic prescription if a patient presented to the pharmacy within 24 h of seeing a doctor. Instead, they would advise the patient to wait and fill the prescription if they are not improving. CONCLUSION The concept of delayed or a 'wait and see' antibiotic prescription was well received by the participating community pharmacists. These healthcare professionals are well placed to be effective stewards of antibiotics and can play an important role in collaboration with other healthcare professionals to optimise the quality use of antibiotics in primary care.
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Affiliation(s)
- Minyon L Avent
- Statewide Antimicrobial Stewardship Program, Queensland Health, Brisbane, QLD, Australia.,UQ Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, QLD, Australia
| | - Jasmina Fejzic
- School of Pharmacy, The University of Queensland, Brisbane, QLD, Australia
| | - Mieke L van Driel
- Primary Care Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
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Kapadia SN, Abramson EL, Carter EJ, Loo AS, Kaushal R, Calfee DP, Simon MS. The Expanding Role of Antimicrobial Stewardship Programs in Hospitals in the United States: Lessons Learned from a Multisite Qualitative Study. Jt Comm J Qual Patient Saf 2018; 44:68-74. [PMID: 29389462 DOI: 10.1016/j.jcjq.2017.07.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 07/21/2017] [Accepted: 07/31/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Misuse of antibiotics can lead to the development of antibiotic resistance, which adversely affects morbidity, mortality, length of stay, and cost. To combat the threat of antimicrobial resistance, The Joint Commission and the Centers for Medicare & Medicaid Services have initiated or proposed requirements for hospitals to have antimicrobial stewardship programs (ASPs), but implementation remains challenging. A key-informant interview study was conducted to describe the characteristics and innovative strategies of leading ASPs. METHODS Semistructured interviews were conducted with 12 program leaders at four ASPs in the United States, chosen by purposive sampling on the basis of national reputation, scholarship, and geography. Questions focused on ASP implementation, program structure, strengths, weaknesses, lessons learned, and future directions. Content analysis was used to identify dominant themes. RESULTS Three major themes were identified. The first was evolution of ASPs from a top-down structure to a more diffuse approach involving unit-based pharmacists, multidisciplinary staff, and shared responsibility for antimicrobial prescribing under the ASPs' leadership. The second theme was integration of information technology (IT) systems, which enabled real-time interventions to optimize antimicrobial therapy and patient management. The third was barriers to technology integration, including limited resources for data analysis and poor interoperability between software systems. CONCLUSION The study provides valuable insights on program implementation at a sample of leading ASPs across the United States. These ASPs used expansion of personnel to amplify the ASP's impact and integrated IT resources into daily work flow to improve efficiency. These findings can be used to guide implementation at other hospitals and aid in future policy development.
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Micallef C, Ashiru-Oredope D, Hansraj S, Denning DW, Agrawal SG, Manuel RJ, Schelenz S, Guy R, Muller-Pebody B, Patel R, Howard P, Hopkins S, Johnson E, Enoch DA. An investigation of antifungal stewardship programmes in England. J Med Microbiol 2017; 66:1581-1589. [PMID: 29068278 DOI: 10.1099/jmm.0.000612] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
PURPOSE We sought to explore the current status of antifungal stewardship (AFS) initiatives across National Health Service (NHS) Trusts within England, the challenges and barriers, as well as ways to improve current AFS programmes. METHODOLOGY An electronic survey was sent to all 155 acute NHS Trusts in England. A total of 47 Trusts, corresponding to 30 % of English acute Trusts, responded to the the survey; 46 Trusts (98 %) had an antimicrobial stewardship (AMS) programme but only 5 (11 %) had a dedicated AFS programme. Overall, 20 (43 %) Trusts said they included AFS as part of their AMS programmes. From those conducting AFS programmes, 7 (28 %) have an AFS/management team, 16 (64 %) monitor and report on antifungal usage, 5 (20 %) have dedicated AFS ward rounds and 12 (48 %) are directly involved in the management of invasive fungal infections.Results/Key findings. Altogether, 13 acute Trusts (52 %) started their AFS programme to manage costs, whilst 12 (48 %) commenced the programme due to clinical need; 27 (73 %) declared that they would increase their AFS initiatives if they could. Of those without an AFS programme, 14 (67 %) responded that this was due to lack of resources/staff time. Overall, 12 Trusts (57 %) responded that the availability of rapid diagnostics and clinical support would enable them to conduct AFS activities. CONCLUSION Although a minority of Trusts conduct dedicated AFS programmes, nearly half include AFS as part of routine AMS activities. Cost issues are the main driver for AFS, followed by clinical need. The availability of rapid diagnostics and clinical support could help increase AFS initiatives.
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Affiliation(s)
- Christianne Micallef
- Pharmacy Department, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital Biomedical Campus, Hills Road, Cambridge CB2 0QQ, UK
| | - Diane Ashiru-Oredope
- Antimicrobial Resistance Programme, Public Health England, 61 Colindale Avenue, London NW9 5EQ, UK
| | - Sejal Hansraj
- Antimicrobial Resistance Programme, Public Health England, 61 Colindale Avenue, London NW9 5EQ, UK
| | - David W Denning
- National Aspergillosis Centre, University Hospital of South Manchester, The University of Manchester and Manchester Academic Health Science Centre, Manchester, UK
| | - Samir G Agrawal
- Bart's Health NHS Trust and Blizard Institute, Queen Mary University of London, London, UK
| | - Rohini J Manuel
- National Infection Service, Public Health England, Public Health Laboratory London, London, UK
| | - Silke Schelenz
- Royal Brompton Hospital & Harefield Hospitals NHS FT, Sydney Street, London SW3 6NP, UK
| | - Rebecca Guy
- Healthcare Associated Infection and Antimicrobial Resistance Department, National Infection Service, Public Health England, 61 Colindale Avenue, London, UK
| | - Berit Muller-Pebody
- Healthcare Associated Infection and Antimicrobial Resistance Department, National Infection Service, Public Health England, 61 Colindale Avenue, London, UK
| | - Rakhee Patel
- Pharmacy Department, Darent Valley Hospital, Dartford and Gravesham NHS Trust, Darenth Wood Road, Dartford, Kent DA2 8DA, UK
| | - Philip Howard
- Pharmacy Department, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Susan Hopkins
- Healthcare Associated Infection and Antimicrobial Resistance Department, National Infection Service, Public Health England, 61 Colindale Avenue, London, UK
| | - Elizabeth Johnson
- Public Health England South West Laboratory, Myrtle Road, Kingsdown, Bristol BS2 8EL, UK
| | - David A Enoch
- National Infection Service, Public Health England, Microbiology Laboratory, Addenbrook's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Papoutsi C, Mattick K, Pearson M, Brennan N, Briscoe S, Wong G. Social and professional influences on antimicrobial prescribing for doctors-in-training: a realist review. J Antimicrob Chemother 2017; 72:2418-2430. [PMID: 28859445 PMCID: PMC5890780 DOI: 10.1093/jac/dkx194] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 05/20/2017] [Accepted: 05/22/2017] [Indexed: 12/14/2022] Open
Abstract
Background Antimicrobial resistance has led to widespread implementation of interventions for appropriate prescribing. However, such interventions are often adopted without an adequate understanding of the challenges facing doctors-in-training as key prescribers. Methods The review followed a realist, theory-driven approach to synthesizing qualitative, quantitative and mixed-methods literature. Consistent with realist review quality standards, articles retrieved from electronic databases were systematically screened and analysed to elicit explanations of antimicrobial prescribing behaviours. These explanations were consolidated into a programme theory drawing on social science and learning theory, and shaped though input from patients and practitioners. Results By synthesizing data from 131 articles, the review highlights the complex social and professional dynamics underlying antimicrobial prescribing decisions of doctors-in-training. The analysis shows how doctors-in-training often operate within challenging contexts (hierarchical relationships, powerful prescribing norms, unclear roles and responsibilities, implicit expectations about knowledge levels, uncertainty about application of knowledge in practice) where they prioritize particular responses (fear of criticism and individual responsibility, managing one's reputation and position in the team, appearing competent). These complex dynamics explain how and why doctors-in-training decide to: (i) follow senior clinicians' prescribing habits; (ii) take (or not) into account prescribing aids, advice from other health professionals or patient expectations; and (iii) ask questions or challenge decisions. This increased understanding allows for targeted tailoring, design and implementation of antimicrobial prescribing interventions. Conclusions This review contributes to a better understanding of how antimicrobial prescribing interventions for doctors-in-training can be embedded more successfully in the hierarchical and inter-professional dynamics of different healthcare settings.
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Affiliation(s)
- Chrysanthi Papoutsi
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford OX2 6GG, UK
| | - Karen Mattick
- Centre for Research in Professional Learning, University of Exeter, St Luke’s Campus, Exeter EX1 2LU, UK
| | - Mark Pearson
- National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care South West Peninsula, Institute of Health Research, University of Exeter Medical School, South Cloisters, St Luke’s Campus, Exeter EX1 2LU, UK
| | - Nicola Brennan
- Collaboration for the Advancement of Medical Education Research & Assessment (CAMERA), Peninsula Schools of Medicine & Dentistry, Plymouth University, Drake Circus Plymouth, Devon PL4 8AA, UK
| | - Simon Briscoe
- National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care South West Peninsula, Institute of Health Research, University of Exeter Medical School, South Cloisters, St Luke’s Campus, Exeter EX1 2LU, UK
| | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford OX2 6GG, UK
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Owens R, Jones LF, Moore M, Pilat D, McNulty C. Self-Assessment of Antimicrobial Stewardship in Primary Care: Self-Reported Practice Using the TARGET Primary Care Self-Assessment Tool. Antibiotics (Basel) 2017; 6:E16. [PMID: 28813003 PMCID: PMC5617980 DOI: 10.3390/antibiotics6030016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 08/09/2017] [Accepted: 08/11/2017] [Indexed: 11/16/2022] Open
Abstract
Multifaceted antimicrobial stewardship (AMS) interventions including: antibiotic guidance, reviews of antibiotic use using audits, education, patient facing materials, and self-assessment, are successful in improving antimicrobial use. We aimed to measure the self-reported AMS activity of staff completing a self-assessment tool (SAT). The Royal College of General Practitioners (RCGP)/Public Health England (PHE) SAT enables participants considering an AMS eLearning course to answer 12 short questions about their AMS activities. Questions cover guidance, audit, and reflection about antibiotic use, patient facing materials, and education. Responses are recorded digitally. Data were collated, anonymised, and exported into Microsoft Excel. Between November 2014 and June 2016, 1415 users completed the SAT. Ninety eight percent reported that they used antibiotic guidance for treating common infections and 63% knew this was available to all prescribers. Ninety four percent of GP respondents reported having used delayed prescribing when appropriate, 25% were not using Read codes, and 62% reported undertaking a practice-wide antibiotic audit in the last two years, of which, 77% developed an audit action plan. Twenty nine percent had undertaken other antibiotic-related clinical courses. Fifty six percent reported sharing patient leaflets covering infection. Many prescribers reported undertaking a range of AMS activities. GP practice managers should ensure that all clinicians have access to prescribing guidance. Antibiotic audits should be encouraged to enable GP staff to understand their prescribing behaviour and address gaps in good practice. Prescribers are not making full use of antibiotic prescribing-related training opportunities. Read coding facilitates more accurate auditing and its use by all clinicians should be encouraged.
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Affiliation(s)
| | | | - Michael Moore
- Department of Primary Care and Population Sciences, Aldermoor Health Centre Southampton, University of Southampton, Southampton SO16 5ST, UK.
| | - Dirk Pilat
- Royal College of General Practitioners, London NW1 2FB, UK.
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McGowan JE. The 2016 Garrod Lecture: The role of the healthcare epidemiologist in antimicrobial chemotherapy-a view from the USA. J Antimicrob Chemother 2017; 71:2370-8. [PMID: 27550989 DOI: 10.1093/jac/dkw292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Antimicrobial chemotherapy now spans 80 years and four generations. The healthcare epidemiologist has an important role to play in this field. Efforts focus in three areas: (i) minimizing the transmission of antimicrobial-resistant bacteria in healthcare settings (infection control); (ii) optimizing use of currently available antibacterial drugs (antibiotic stewardship); and (iii) recognizing and responding to opportunities for new drug development. For each area, the epidemiologist provides data that address four practical questions-'What is the problem?', 'What should be done?', 'Is it being done?' and 'Is it working?'. A team approach is crucial to acting on the epidemiological data. Examples are presented to illustrate different roles of the epidemiologist, and tools and measures that have been developed to address some problems of current importance. Monitoring of quality, integrity and security of data remains a major focus. The epidemiologist will continue to have a key role in antimicrobial chemotherapy.
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Affiliation(s)
- John E McGowan
- Department of Epidemiology, Rollins School of Public Health of Emory University Department of Medicine (Infectious Diseases), Emory University School of Medicine, 1518 Clifton Rd NE, Atlanta, GA 30322, USA
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Johnson AP. Contribution of
JAC
to antimicrobial stewardship. J Antimicrob Chemother 2016; 71:3001-3007. [DOI: 10.1093/jac/dkw373] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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UK initiatives to reduce antimicrobial resistant infections, 2013-2018. INTERNATIONAL JOURNAL OF HEALTH GOVERNANCE 2016. [DOI: 10.1108/ijhg-02-2016-0013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
– The purpose of this paper is to highlight the local, national and global actions from the UK to reduce the impact of antimicrobial resistance (AMR) on human health.
Design/methodology/approach
– Synthesis of UK government policy, surveillance and research on AMR.
Findings
– Activities that are taking place by the UK government, public health and professional organisations are highlighted.
Originality/value
– This paper describes the development and areas for action of the UK AMR strategy. It highlights the many interventions that are being delivered to reduce antibiotic use and antimicrobial resistant infections.
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