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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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2
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Channon-Wells S, Patel S. The omission of children from the UK's antimicrobial strategy must be tackled. BMJ 2023; 381:1432. [PMID: 37348902 DOI: 10.1136/bmj.p1432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/24/2023]
Affiliation(s)
- Samuel Channon-Wells
- Department of Infectious Disease, Section of Paediatric Infectious Disease, Imperial College London, London, UK
| | - Sanjay Patel
- Department of Paediatric Infectious Diseases and Immunology, Southampton Children's Hospital, Southampton, UK
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3
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Wang L, Zhang D, Liu J, Tang Y, Zhou Q, Lai X, Zheng F, Wang Q, Zhang X, Cheng J. The mediating role of incentives in association between leadership attention and self-perceived continuous improvement in infection prevention and control among medical staff: A cross-sectional survey. Front Public Health 2023; 11:984847. [PMID: 36844830 PMCID: PMC9947710 DOI: 10.3389/fpubh.2023.984847] [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: 07/04/2022] [Accepted: 01/18/2023] [Indexed: 02/11/2023] Open
Abstract
Objectives Promoting improvement in Infection Prevention and Control (IPC) is an important part of improving the quality of care. The influence of leadership attention and incentives on the self-perceived continuous improvement in IPC has drawn a lot of attention, but relevant academic research is still lacking. The objective of this study is to explore the effect of leadership attention on self-perceived continuous improvement in IPC among medical staff and its underlying mechanisms. Method The 3,512 medical staff from 239 health facilities in Hubei, China, were surveyed online during September 2020. Data on leadership attention, incentives, and improvement in Infection Prevention and Control were collected using self-administered questionnaires. Correlation analysis was used to analyze the relationship between leadership attention, incentives, and improvement in Infection Prevention and Control. Amos 24.0 was used to analyze the mediating role. Results The scores of leadership attention, incentives and self-perceived continuous improvement in Infection Prevention and Control were all high. The score of leadership attention was the highest (4.67 ± 0.59), followed by self-perceived continuous improvement (4.62 ± 0.59) and incentives in Infection Prevention and Control (4.12 ± 0.83). Leadership attention positively affected self-perceived continuous improvement in Infection Prevention and Control (β = 0.85, 95% CI = [0.83, 0.87]). Moreover, incentives partially mediated the effect of leadership attention on self-perceived continuous improvement in Infection Prevention and Control among medical staff (β = 0.13, 95% CI = [0.12, 0.15]). Conclusion Leadership attention positively affects self-perceived continuous improvement in Infection Prevention and Control among medical staff, and incentives mediates this relationship. The present study has valuable implications for self-perceived continuous improvement in Infection Prevention and Control from the perspective of leadership attention and incentives.
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Affiliation(s)
- Lu Wang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Dandan Zhang
- The First Affiliated Hospital, Nanjing Medical University, Human Resource Office, Nanjing, China
| | - Junjie Liu
- School of Statistics and Mathematics, Central University of Finance and Economics, Beijing, China
| | - Yuqing Tang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qian Zhou
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaoquan Lai
- Department of Nosocomial Infection, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Feiyang Zheng
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qianning Wang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xinping Zhang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China,*Correspondence: Xinping Zhang ✉
| | - Jing Cheng
- Department of Emergency, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China,Jing Cheng ✉
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4
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Singh S, Ark R, Tatlock J, Mandalia S, Chung C, Azadian B, Hughes S, Mughal N, Moore LSP, Singh S. Evaluating the long-term impact of an antimicrobial stewardship programme in a Central London mixed medical and surgical intensive care unit. JAC Antimicrob Resist 2022; 4:dlac108. [PMID: 36226228 PMCID: PMC9549738 DOI: 10.1093/jacamr/dlac108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 09/16/2022] [Indexed: 02/05/2023] Open
Abstract
Background Antimicrobial overuse causes increased antimicrobial resistance in ICUs; antimicrobial stewardship programmes (ASPs) aim to optimize usage. Following an MDR Acinetobacter baumannii (MRAb) outbreak in 2008, an ASP was implemented at a London ICU, and then continued as a long-term programme. This study aimed to determine long-term changes in antimicrobial prescribing 9 years on. Methods Data were collected from ICU patients in 2008 immediately before ASP implementation, and thereafter for 6 month cohort periods in 2010-2011, 2012 and 2017. Antimicrobial usage in DDD per 1000 occupied bed days (OBD) were compared. Multivariate linear regression models for antimicrobial days were fitted, adjusting for APACHE II score and patient days. Antimicrobial resistance in Pseudomonas aeruginosa (as an indicator organism) was compared across cohort periods. Findings Across 400 patients over 9 years, antimicrobial use changed significantly (P < 0.011) and remained lower in all post-ASP cohorts compared with pre-ASP [(2008; 1827 DDD/1000 OBD), (2010; 1264 DDD/1000 OBD), (2012; 1270 DDD/1000 OBD) and (2017; 1566 DDD/1000 OBD)]. There was reduction in usage of all antimicrobial classes except β-lactams (where there was no significant increase nor decrease, P = 0.178) and aminoglycosides (where there was a significant increase in usage, P < 0.0001). The latter was temporally associated with restrictions on specific carbapenems. There was an increase in carbapenem-resistant P. aeruginosa in 2012 only (P = 0.028) but not subsequently. Conclusions Following ASP implementation after an outbreak of MRAb, reduced antimicrobial prescribing was maintained 9 years on. We identify several factors influencing successful long-term maintenance of ASPs in ICUs.
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Affiliation(s)
| | | | - Jason Tatlock
- Adult Intensive Care Unit, Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, UK
| | - Sundhiya Mandalia
- Faculty of Medicine, Imperial College London, South Kensington Campus, London SW7 2AZ, UK
| | - Christine Chung
- Adult Intensive Care Unit, Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, UK
| | - Berge Azadian
- Faculty of Medicine, Imperial College London, South Kensington Campus, London SW7 2AZ, UK
- Adult Intensive Care Unit, Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, UK
| | - Stephen Hughes
- Adult Intensive Care Unit, Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, UK
| | - Nabeela Mughal
- Faculty of Medicine, Imperial College London, South Kensington Campus, London SW7 2AZ, UK
- Adult Intensive Care Unit, Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, UK
- North West London Pathology, Imperial College Healthcare NHS Trust, Fulham Palace Road, London W6 8RF, UK
| | - Luke S P Moore
- Faculty of Medicine, Imperial College London, South Kensington Campus, London SW7 2AZ, UK
- Adult Intensive Care Unit, Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, UK
- North West London Pathology, Imperial College Healthcare NHS Trust, Fulham Palace Road, London W6 8RF, UK
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Du Cane Road, London W12 0NN, UK
| | - Suveer Singh
- Corresponding author. E-mail: @respitudoc, @dr_luke_moore
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5
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Iwamoto N, Morisaki N, Uda K, Kasai M, Kodama EN, Ohmagari N, Miyairi I. Change in use of pediatric oral antibiotics in Japan, pre- and post-implementation of an antimicrobial resistance action plan. Pediatr Int 2022; 64:e15197. [PMID: 35770781 DOI: 10.1111/ped.15197] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 02/14/2022] [Accepted: 03/16/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Most antimicrobials are prescribed to outpatients, making outpatient antibiotic prescription an important target for antibiotic stewardship. A national antimicrobial resistance (AMR) action plan was developed in 2016 by the Japanese government with various antimicrobials steawardship activities for pediatric outpatients. We aimed to evaluate changes in antibiotic use pre- and post-implementation of the AMR action plan. METHODS All antimicrobials prescribed to pediatric outpatients in Japan from 2011 to 2018 were retrospectively analyzed using data from a national database. Antimicrobials dispensed for patients aged ≤19 years were reviewed. Antimicrobial use was surveyed by age, year of use, type of antimicrobial prescribed, and prescribing facility. Five cities were selected as pilot areas to investigate the variations, based on the clinical specialties of the prescribing physicians. RESULTS Antimicrobial usage varied with age. Specifically, usage decreased post-AMR in patients aged ≤8 years and increased in those aged >15 years. Further, antimicrobial prescriptions tended to decrease after 2016 in primary care clinics and hospitals. In the pilot areas of the study, 35% of all oral antimicrobials were prescribed in otolaryngology departments, and 8% were prescribed in dermatology clinics. Notably, antimicrobial prescriptions from both departments showed an upward trend from 2011 to 2018. CONCLUSION The use of antimicrobial agents decreased in children younger than 8 years in pediatric clinics, hospitals, and internal medicine clinics. However, use increased in children older than 15 years and in other specialty clinics. Settings with an increasing use of antimicrobials are potential targets for the next antibiotic stewardship program and should be investigated in detail.
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Affiliation(s)
- Noriko Iwamoto
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan.,Department of Emerging and Reemerging Infectious Diseases, Tohoku University School of Medicine, Miyagi, Japan.,Division of Infectious Diseases, Department of Medical Subspecialties, National Center for Child Health and Development, Tokyo, Japan
| | - Naho Morisaki
- Department of Social Medicine, Research Institute, National Center for Child Health and Development, Tokyo, Japan
| | - Kazuhiro Uda
- Division of Infectious Diseases, Department of Medical Subspecialties, National Center for Child Health and Development, Tokyo, Japan.,Department of Pediatrics, Okayama University Hospital, Okayama City, Okayama, Japan
| | - Masashi Kasai
- Division of Infectious Diseases, Department of Pediatrics, Hyogo Prefectural Kobe Children Hospital, Kobe City, Hyogo, Japan
| | - Eiichi N Kodama
- Division of Infectious Diseases, School of Medicine, International Research Institute of Disaster Science, and Tohoku Medical Megabank Organization, Tohoku University, Sendai, Miyagi, Japan
| | - Norio Ohmagari
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan.,Department of Emerging and Reemerging Infectious Diseases, Tohoku University School of Medicine, Miyagi, Japan
| | - Isao Miyairi
- Division of Infectious Diseases, Department of Medical Subspecialties, National Center for Child Health and Development, Tokyo, Japan.,Department of Microbiology, Immunology, and Biochemistry, University of Tennessee Health Science Center, Memphis, TN, USA.,Department of Pediatrics, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
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6
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Budgell EP, Davies TJ, Donker T, Hopkins S, Wyllie DH, Peto TEA, Gill MJ, Llewelyn MJ, Walker AS. Impact of hospital antibiotic use on patient-level risk of death among 36,124,372 acute and medical admissions in England. J Infect 2021; 84:311-320. [PMID: 34963640 DOI: 10.1016/j.jinf.2021.12.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 12/03/2021] [Accepted: 12/17/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Initiatives to curb hospital antibiotic use might be associated with harm from under-treatment. We examined the extent to which variation in hospital antibiotic prescribing is associated with mortality risk in acute/general medicine inpatients. METHODS This ecological analysis examined Hospital Episode Statistics from 36,124,372 acute/general medicine admissions (≥16y) to 135 acute hospitals in England, 01/April/2010-31/March/2017. Random-effects meta-regression was used to investigate whether heterogeneity in adjusted 30-day mortality was associated with hospital-level antibiotic use, measured in defined-daily-doses (DDD)/1,000 bed-days. Models also considered DDDs/1,000 admissions and DDDs for narrow-spectrum/broad-spectrum antibiotics, parenteral/oral, and local interpretations of World Health Organization Access, Watch, and Reserve antibiotics. RESULTS Hospital-level antibiotic DDDs/1,000 bed-days varied 15-fold with comparable variation in broad-spectrum, parenteral, and Reserve antibiotic use. After extensive adjusting for hospital case-mix, the probability of 30-day mortality changed -0.010% (95% CI: -0.064,+0.044) for each increase of 500 hospital-level antibiotic DDDs/1,000 bed-days. Analyses of other metrics of antibiotic use showed no consistent association with mortality risk. CONCLUSIONS We found no evidence that wide variation in hospital antibiotic use is associated with adjusted mortality risk in acute/general medicine inpatients. Using low-prescribing hospitals as benchmarks could help drive safe and substantial reductions in antibiotic consumption of up-to one-third in this population.
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Affiliation(s)
- Eric P Budgell
- Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Timothy J Davies
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Tjibbe Donker
- Institute for Infection Prevention and Hospital Epidemiology, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Susan Hopkins
- National Infection Service, Public Health England, UK
| | | | - Tim E A Peto
- Nuffield Department of Medicine, University of Oxford, Oxford, UK; NIHR Biomedical Research Centre, Oxford, UK; National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Oxford, UK
| | - Martin J Gill
- Clinical Microbiology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Martin J Llewelyn
- Global Health and Infectious Diseases, Brighton and Sussex Medical School, University of Sussex, Brighton, UK; Department of Microbiology and Infection, Royal Sussex County Hospital, Brighton, UK
| | - A Sarah Walker
- Nuffield Department of Medicine, University of Oxford, Oxford, UK; NIHR Biomedical Research Centre, Oxford, UK; National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Oxford, UK
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7
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Farrell S, McKernan C, Benson T, Elliott C, Dean M. Understanding farmers' and veterinarians' behavior in relation to antimicrobial use and resistance in dairy cattle: A systematic review. J Dairy Sci 2021; 104:4584-4603. [PMID: 33612225 DOI: 10.3168/jds.2020-19614] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 12/11/2020] [Indexed: 11/19/2022]
Abstract
To tackle antimicrobial resistance, it is vital that farmers' and veterinarians' antimicrobial use behaviors and attitudes toward resistance are understood so that we can identify how beliefs and motives influence practices. Current literature details qualitative and quantitative research that explores the knowledge, attitudes and perceptions of dairy farmers and veterinarians with respect to antimicrobial resistance and antimicrobial practices, and the reported findings are varied and conflicting. Our objective was to conduct a systematic review to assess the evidence and knowledge gaps in the published literature. We identified articles via database searches of Embase, Medline, PubMed, Scopus, and Web of Science; we limited findings to published articles available in English with no publication year restrictions. Article screening was conducted at 3 levels: title, abstract, and full text. Of the 349 articles identified, 35 were retained for systematic review. Transparency of reporting was assessed for each study using the Consolidated Criteria for Reporting Qualitative Research (COREQ) framework. Quality was assessed using the Critical Appraisal Skills Programme qualitative checklist. Findings relating to dairy farmers' and veterinarians' knowledge, attitudes, and perceptions on antimicrobial resistance and practices were thematically analyzed. The comprehensiveness of reporting was variable: studies reported 5 to 26 of the 32 COREQ checklist items. Five key themes emerged from the data: knowledge and awareness of antimicrobial resistance; factors influencing farmer and veterinarian decision-making; perceived barriers and facilitators to reduced antimicrobial use; perceived responsibility for antimicrobial resistance; and the role of the farmer and veterinarian relationship in reducing antimicrobial use. Awareness of prudent antimicrobial use was not uniform between studies. Many factors influence farmers' and veterinarians' decisions to use antimicrobials, including animal welfare and available resources. The farmer-veterinarian relationship is a potential barrier or facilitator of reduced antimicrobial use, depending on the perceived relationship dynamic. Encouraging collaboration between farmers and veterinarians could lead to shared responsibility for reducing antimicrobial use. This review provided a coherent picture of what is currently known and identified gaps in the current knowledge to inform future behavioral intervention research. Increased knowledge, skill development, resources, engagement, and further research to address the gaps we identified are the main recommendations to effectively overcome barriers, elicit appropriate behavior change, and achieve reduced antimicrobial use in dairy cattle.
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Affiliation(s)
- S Farrell
- Institute for Global Food Security, School of Biological Sciences, Queen's University Belfast, 19 Chlorine Gardens, Belfast BT9 5DL, United Kingdom
| | - C McKernan
- Institute for Global Food Security, School of Biological Sciences, Queen's University Belfast, 19 Chlorine Gardens, Belfast BT9 5DL, United Kingdom
| | - T Benson
- Institute for Global Food Security, School of Biological Sciences, Queen's University Belfast, 19 Chlorine Gardens, Belfast BT9 5DL, United Kingdom
| | - C Elliott
- Institute for Global Food Security, School of Biological Sciences, Queen's University Belfast, 19 Chlorine Gardens, Belfast BT9 5DL, United Kingdom
| | - M Dean
- Institute for Global Food Security, School of Biological Sciences, Queen's University Belfast, 19 Chlorine Gardens, Belfast BT9 5DL, United Kingdom.
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8
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Ourani M, Honda NS, MacDonald W, Roberts J. Evaluation of evidence-based urinalysis reflex to culture criteria: Impact on reducing antimicrobial usage. Int J Infect Dis 2020; 102:40-44. [PMID: 33011278 DOI: 10.1016/j.ijid.2020.09.1471] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 09/07/2020] [Accepted: 09/26/2020] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVES To implement evidence-based urinalysis (UA) reflex criteria and to evaluate the impact of the intervention on reducing unnecessary antibiotic usage. METHODS A prospective intervention study was conducted on 4130 urine samples that were subjected to UA during March to May 2020. Results were analyzed in order to evaluate the effectiveness of newly implemented evidence-based criteria in predicting positive urine cultures. The intervention involved implementing evidence-based UA reflex criteria to ensure a high predictive value of the UA reflex parameters. Multivariable logistic regression was utilized to evaluate the effectiveness of these UA parameters in predicting positive urine cultures and to assess the impact of the new UA criteria on antibiotic usage. RESULTS A total of 4130 patient samples were included in the study; 60.1% (n = 2484) were from female patients and 39.9% (n = 1646) were from male patients. The total number of negative urine reflex samples was 3116, which accounted for 75.4% of the total UA reflex samples. In contrast, 24.6% of the urine reflex samples (n = 1014) returned positive UA results and were reflexed to urine culture. Among the urine samples that were cultured, 9% (n = 91) were negative urine cultures, while 91.0% (n = 923) were positive urine cultures. Chi-square analysis indicated highly statistically significant associations between the combination parameters of (≥5 white blood cells (WBCs) and positive nitrite) and positive urine cultures (Chi-square = 516.428, p < 0.001) and (≥5 WBCs and moderate or large esterase) and positive urine cultures (Chi-square = 503.387, p < 0.001). Additionally, Chi-square analysis indicated a highly statistically significant association between the combination parameters of (≥5 WBCs and ≥1 bacteria) and positive urine cultures (Chi-square = 434.806, p < 0.001). The statistical analysis showed that the implementation of evidence-based UA reflex criteria significantly decreased the number of urine cultures performed and potentially decreased the number of patients inappropriately treated with antibiotics from 45.1% to 9%. CONCLUSIONS In conclusion, ≥5 WBCs and positive nitrite yielded the highest positive predictive value of 98.00% and showed a highly significant association with positive urine cultures. It was observed that the new UA reflex criteria are highly effective in predicting positive urine cultures, thus potentially resulting in the reduction of unnecessary antibiotic usage.
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Affiliation(s)
- Mohammad Ourani
- Department of Pathology and Laboratory Services, PIH Health in Whittier, CA, USA.
| | - Nathan S Honda
- Department of Pathology and Laboratory Services, PIH Health in Whittier, CA, USA
| | - William MacDonald
- Department of Pathology and Laboratory Services, PIH Health in Downey, CA, USA
| | - Jill Roberts
- College of Public Health, University of South Florida, FL, USA
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9
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Thandar MM, Baba T, Matsuoka S, Ota E. Interventions to reduce non-prescription antimicrobial sales in community pharmacies. Hippokratia 2020. [DOI: 10.1002/14651858.cd013722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Moe Moe Thandar
- Bureau of International Health Cooperation; National Center for Global Health and Medicine; Shinjuku-ku Japan
| | - Toshiaki Baba
- Bureau of International Health Cooperation; National Center for Global Health and Medicine; Shinjuku-ku Japan
- Minds Tokyo GRADE Center, Department of Evidence-Based Medicine and Guidelines; Japan Council of Quality Health Care; Chiyoda-ku Japan
| | - Sadatoshi Matsuoka
- Bureau of International Health Cooperation; National Center for Global Health and Medicine; Shinjuku-ku Japan
| | - Erika Ota
- Global Health Nursing, Graduate School of Nursing Science; St. Luke's International University; Chuo-ku Japan
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10
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Stordeur F, Miliani K, Lacavé L, Rogues AM, Dumartin C, Alfandari S, Astagneau P, L'Hériteau F. How to measure hospital antibiotic consumption: comparison of two methods from data surveillance in France. JAC Antimicrob Resist 2020; 2:dlaa059. [PMID: 34223016 PMCID: PMC8210307 DOI: 10.1093/jacamr/dlaa059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 06/18/2020] [Accepted: 06/24/2020] [Indexed: 11/23/2022] Open
Abstract
Background Antibiotic use (ABU) surveillance in healthcare facilities (HCFs) is essential to guide stewardship. Two methods are recommended: antibiotic consumption (ABC), expressed as the number of DDD/1000 patient-days; and prevalence of antibiotic prescription (ABP) measured through point prevalence surveys. However, no evidence is provided about whether they lead to similar conclusions. Objectives To compare ABC and ABP regarding HCF ranking and their ability to identify outliers. Methods The comparison was made using 2012 national databases from the antibiotic surveillance network and prevalence study. HCF rankings according to each method were compared with Spearman’s correlation coefficient. Analyses included the ABU from entire HCFs as well as according to type, clinical ward and by antibiotic class and specific molecule. Results A total of 1076 HCFs were included. HCF rankings were strongly correlated in the whole cohort. The correlation was stronger for HCFs with a higher number of beds or with a low or moderate proportion of acute care beds. ABU correlation between ABC or ABP was globally moderate or weak in specific wards. Furthermore, the two methods did not identify the same outliers, whichever HCF characteristics were analysed. Correlation between HCF ranking varied according to the antibiotic class. Conclusions Both methods ranked HCFs similarly overall according to ABC or ABP; however, major differences were observed in ranking of clinical wards, antibiotic classes and detection of outliers. ABC and ABP are two markers of ABU that could be used as two complementary approaches to identify targets for improvement.
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Affiliation(s)
- Florence Stordeur
- Centre hospitalier intercommunal de Poissy St Germain, 10 rue du champ Gaillard, 78100 Poissy, France
| | - Katiuska Miliani
- Centre d'appui pour la prévention des infections associées aux soins (CPias) Ile-de-France, Paris, France
| | - Ludivine Lacavé
- Assistance Publique - Hôpitaux de Paris (AP-HP), délégation à la recherche clinique et à l'innovation (DRCI), Paris, France
| | - Anne-Marie Rogues
- Université Bordeaux, Inserm, Bordeaux Population Health Research Center, Team Pharmacoepidemiology, UMR 1219, F-33000 Bordeaux, France.,CHU Bordeaux, Hygiène hospitalière, F-33000 Bordeaux, France
| | - Catherine Dumartin
- Université Bordeaux, Inserm, Bordeaux Population Health Research Center, Team Pharmacoepidemiology, UMR 1219, F-33000 Bordeaux, France.,CHU Bordeaux, CPias Nouvelle Aquitaine, F-33000 Bordeaux, France
| | | | - Pascal Astagneau
- Centre d'appui pour la prévention des infections associées aux soins (CPias) Ile-de-France, Paris, France.,Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, F-75013 Paris, France
| | - François L'Hériteau
- Centre d'appui pour la prévention des infections associées aux soins (CPias) Ile-de-France, Paris, France
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11
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Roope LSJ, Buchanan J, Morrell L, Pouwels KB, Sivyer K, Mowbray F, Abel L, Cross ELA, Yardley L, Peto T, Walker AS, Llewelyn MJ, Wordsworth S. Why do hospital prescribers continue antibiotics when it is safe to stop? Results of a choice experiment survey. BMC Med 2020; 18:196. [PMID: 32727604 PMCID: PMC7391515 DOI: 10.1186/s12916-020-01660-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 06/08/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Deciding whether to discontinue antibiotics at early review is a cornerstone of hospital antimicrobial stewardship practice worldwide. In England, this approach is described in government guidance ('Start Smart then Focus'). However, < 10% of hospital antibiotic prescriptions are discontinued at review, despite evidence that 20-30% could be discontinued safely. We aimed to quantify the relative importance of factors influencing prescriber decision-making at review. METHODS We conducted an online choice experiment, a survey method to elicit preferences. Acute/general hospital prescribers in England were asked if they would continue or discontinue antibiotic treatment in 15 hypothetical scenarios. Scenarios were described according to six attributes, including patients' presenting symptoms and whether discontinuation would conflict with local prescribing guidelines. Respondents' choices were analysed using conditional logistic regression. RESULTS One hundred respondents completed the survey. Respondents were more likely to continue antibiotics when discontinuation would 'strongly conflict' with local guidelines (average marginal effect (AME) on the probability of continuing + 0.194 (p < 0.001)), when presenting symptoms more clearly indicated antibiotics (AME of urinary tract infection symptoms + 0.173 (p < 0.001) versus unclear symptoms) and when patients had severe frailty/comorbidities (AME = + 0.101 (p < 0.001)). Respondents were less likely to continue antibiotics when under no external pressure to continue (AME = - 0.101 (p < 0.001)). Decisions were also influenced by the risks to patient health of continuing/discontinuing antibiotic treatment. CONCLUSIONS Guidelines that conflict with antibiotic discontinuation (e.g. pre-specify fixed durations) may discourage safe discontinuation at review. In contrast, guidelines conditional on patient factors/treatment response could help hospital prescribers discontinue antibiotics if diagnostic information suggesting they are no longer needed is available.
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Affiliation(s)
- Laurence S J Roope
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7LF, UK. .,NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, University of Oxford, Oxford, UK. .,NIHR Health Protection Research Unit (HPRU) in Healthcare Associated Infections and Antimicrobial Resistance at the University of Oxford in partnership with Public Health England (PHE), Oxford, UK.
| | - James Buchanan
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7LF, UK.,NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, University of Oxford, Oxford, UK.,NIHR Health Protection Research Unit (HPRU) in Healthcare Associated Infections and Antimicrobial Resistance at the University of Oxford in partnership with Public Health England (PHE), Oxford, UK
| | - Liz Morrell
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7LF, UK
| | - Koen B Pouwels
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7LF, UK.,NIHR Health Protection Research Unit (HPRU) in Healthcare Associated Infections and Antimicrobial Resistance at the University of Oxford in partnership with Public Health England (PHE), Oxford, UK
| | - Katy Sivyer
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
| | - Fiona Mowbray
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
| | - Lucy Abel
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Elizabeth L A Cross
- Department of Microbiology and Infection, Brighton and Sussex University Hospitals NHS Trust, Eastern Road, Brighton, UK
| | - Lucy Yardley
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK.,School of Psychological Science, University of Bristol, Clifton, UK
| | - Tim Peto
- NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, University of Oxford, Oxford, UK.,Nuffield Department of Medicine, John Radcliffe Hospital, University of Oxford, Oxford, UK.,Oxford University Hospitals NHS Trust, Oxford, UK
| | - A Sarah Walker
- NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, University of Oxford, Oxford, UK.,NIHR Health Protection Research Unit (HPRU) in Healthcare Associated Infections and Antimicrobial Resistance at the University of Oxford in partnership with Public Health England (PHE), Oxford, UK.,Nuffield Department of Medicine, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Martin J Llewelyn
- Department of Microbiology and Infection, Brighton and Sussex University Hospitals NHS Trust, Eastern Road, Brighton, UK.,Brighton and Sussex Medical School, Brighton, UK
| | - Sarah Wordsworth
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7LF, UK.,NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, University of Oxford, Oxford, UK
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12
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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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13
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Muraki Y, Kusama Y, Tanabe M, Hayakawa K, Gu Y, Ishikane M, Yamasaki D, Yagi T, Ohmagari N. Impact of antimicrobial stewardship fee on prescribing for Japanese pediatric patients with upper respiratory infections. BMC Health Serv Res 2020; 20:399. [PMID: 32393267 PMCID: PMC7212615 DOI: 10.1186/s12913-020-05288-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 05/01/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND In 2018, the Japanese medical reimbursement system was revised to introduce a fee for the implementation of an antimicrobial stewardship (AS) fee for pediatric patients. The purpose of this study was to evaluate physicians' prescription behavior following this revision. METHODS We conducted a retrospective observational study from January 1, 2017 to September 30, 2018 of pediatric (< 15 years) outpatients with upper respiratory tract infections (URIs). To assess the pattern of antibiotic prescription for the treatment of pediatric URIs before and after the introduction of the AS fee, we extracted data on pediatric URIs, diagnosed during the study period. Patients were divided based on whether medical facilities claimed AS fees. We defined antibiotic use as the number of antibiotics prescribed, and evaluated the proportion of each class to the total number of antibiotics prescribed. We also recorded the number of medical facilities that each patient visited during the study period. RESULTS The frequency of antibiotic prescription decreased after AS fee implementation, regardless of whether the facility claimed the AS fee, but tended to be lower in facilities that claimed the fee. Additionally, the frequency of antibiotic prescription decreased in all age groups. Despite the reduced frequency of antibiotic prescription, consultation behavior did not change. CONCLUSIONS The AS fee system, which compensates physicians for limiting antibiotic prescriptions, helped to reduce unnecessary antibiotic prescription and is thus a potentially effective measure against antimicrobial resistance.
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Affiliation(s)
- Yuichi Muraki
- Department of Clinical Pharmacoepidemiology, Kyoto Pharmaceutical University, 5, Misasagi-Nakauchi-cho, Yamashina-ku, Kyoto-shi, Kyoto, 607-8414 Japan
| | - Yoshiki Kusama
- Antimicrobial Resistance Clinical Reference Center, Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Masaki Tanabe
- Department of Infection Control and Prevention, Mie University Hospital, Mie, Japan
| | - Kayoko Hayakawa
- Antimicrobial Resistance Clinical Reference Center, Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Yoshiaki Gu
- Antimicrobial Resistance Clinical Reference Center, Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Masahiro Ishikane
- Antimicrobial Resistance Clinical Reference Center, Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Daisuke Yamasaki
- Department of Infection Control and Prevention, Mie University Hospital, Mie, Japan
| | - Tetsuya Yagi
- Department of Infectious Diseases, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Norio Ohmagari
- Antimicrobial Resistance Clinical Reference Center, Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
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14
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Scott S, Twigg MJ, Clark A, Farrow C, May H, Patel M, Taylor J, Wright DJ, Bhattacharya D. Development of a hospital deprescribing implementation framework: A focus group study with geriatricians and pharmacists. Age Ageing 2019; 49:102-110. [PMID: 31711097 PMCID: PMC6939289 DOI: 10.1093/ageing/afz133] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 07/29/2019] [Accepted: 09/05/2019] [Indexed: 01/21/2023] Open
Abstract
Background over 50% of older people in hospital are prescribed a pre-admission medicine that is potentially inappropriate; however, deprescribing by geriatricians and pharmacists is limited. This study aimed to characterise geriatricians’ and pharmacists’ barriers and enablers to deprescribing in hospital. It also intended to develop a framework of intervention components to facilitate implementation of hospital deprescribing. Methods fifty-four geriatricians and pharmacists representing four UK hospitals attended eight focus groups. We designed a topic guide to invite discussions about barriers and enablers to deprescribing. After thematic analysis, themes were mapped to the theoretical domains framework (TDF), enabling prioritisation of domains for behaviour change. We then identified evidence-based intervention components for changing behaviour within prioritised TDF domains. Results geriatricians and pharmacists described several deprescribing enablers in the hospital setting including alignment with their role and generalist knowledge, and routine patient monitoring. Five prioritised TDF domains represent the key barriers and enabler: patient and caregiver attachment to medication (social influence); perceptions that deprescribing is riskier than continuing to prescribe (beliefs about consequences); pharmacists’ working patterns limiting capacity to support deprescribing (environmental context and resources); deprescribing being a low hospital priority (goals) and incentives to deprescribe (reinforcement). Prioritised TDF domains aligned with 44 evidence-based intervention components to address the barriers and enabler to hospital deprescribing. Conclusion the behavioural determinants and their associated intervention components provide a hospital deprescribing implementation framework (hDIF). Intervention components should be selected from the hDIF to provide a theory and evidence-based intervention tailored to hospital contexts.
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Affiliation(s)
- Sion Scott
- School of Pharmacy, University of East Anglia, Norwich NR4 7TJ, UK
- Pharmacy Department, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich NR4 7UY, UK
| | - Michael J Twigg
- School of Pharmacy, University of East Anglia, Norwich NR4 7TJ, UK
| | - Allan Clark
- Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK
| | - Carol Farrow
- Pharmacy Department, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich NR4 7UY, UK
| | - Helen May
- Older People’s Medicine Department, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich NR4 7UY, UK
| | - Martyn Patel
- Older People’s Medicine Department, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich NR4 7UY, UK
| | - Johanna Taylor
- Department of Health Sciences, University of York, York YO10 5DD, UK
| | - David J Wright
- School of Pharmacy, University of East Anglia, Norwich NR4 7TJ, UK
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15
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Cross ELA, Sivyer K, Islam J, Santillo M, Mowbray F, Peto TEA, Walker AS, Yardley L, Llewelyn MJ. Adaptation and implementation of the ARK (Antibiotic Review Kit) intervention to safely and substantially reduce antibiotic use in hospitals: a feasibility study. J Hosp Infect 2019; 103:268-275. [PMID: 31394146 DOI: 10.1016/j.jhin.2019.07.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 07/30/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Antimicrobial stewardship initiatives in secondary care depend on clinicians undertaking antibiotic prescription reviews but decisions to limit antibiotic treatment at review are complex. AIM To assess the feasibility and acceptability of implementing ARK (Antibiotic Review Kit), a behaviour change intervention made up of four components (brief online tool, prescribing decision aid, regular data collection and feedback process, and patient leaflet) to support stopping antibiotic treatment when it is safe to do so among hospitalized patients; before definitive evaluation through a stepped-wedge cluster-randomized controlled trial. METHODS Acceptability of the different intervention elements was assessed for a period of 12 weeks by uptake of the online tool, adoption of the decision aid into prescribing practice, and rates of decisions to stop antibiotics at review (assessed through repeated point-prevalence surveys). Patient perceptions of the information leaflet were assessed through a brief questionnaire. FINDINGS All elements of the intervention were successfully introduced into practice. A total of 132 staff encompassing a broad range of prescribers and non-prescribers completed the online tool (19.4 per 100 acute beds), including 97% (32/33) of the pre-specified essential clinical staff. Among 588 prescription charts evaluated in seven point-prevalence surveys over the 12-week implementation period, 82% overall (76-90% at each survey) used the decision aid. The median antibiotic stop rate post implementation was 36% (range: 29-40% at each survey) compared with 9% pre implementation (P < 0.001). CONCLUSION ARK provides a feasible and acceptable mechanism to support stopping antibiotics safely at post-prescription reviews in an acute hospital setting.
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Affiliation(s)
- E L A Cross
- Brighton and Sussex Medical School, University of Sussex, Falmer, UK
| | - K Sivyer
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
| | - J Islam
- Brighton and Sussex Medical School, University of Sussex, Falmer, UK
| | - M Santillo
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
| | - F Mowbray
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
| | - T E A Peto
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Nuffield Department of Medicine, University of Oxford, Oxford, UK; NIHR Biomedical Centre, Oxford, UK
| | - A S Walker
- Nuffield Department of Medicine, University of Oxford, Oxford, UK; NIHR Biomedical Centre, Oxford, UK
| | - L Yardley
- School of Psychological Science, University of Bristol, Bristol, UK
| | - M J Llewelyn
- Brighton and Sussex Medical School, University of Sussex, Falmer, UK.
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16
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Walker AS, Budgell E, Laskawiec-Szkonter M, Sivyer K, Wordsworth S, Quaddy J, Santillo M, Krusche A, Roope LSJ, Bright N, Mowbray F, Jones N, Hand K, Rahman N, Dobson M, Hedley E, Crook D, Sharland M, Roseveare C, Hobbs FDR, Butler C, Vaughan L, Hopkins S, Yardley L, Peto TEA, Llewelyn MJ. Antibiotic Review Kit for Hospitals (ARK-Hospital): study protocol for a stepped-wedge cluster-randomised controlled trial. Trials 2019; 20:421. [PMID: 31296255 PMCID: PMC6625068 DOI: 10.1186/s13063-019-3497-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 06/05/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND To ensure patients continue to get early access to antibiotics at admission, while also safely reducing antibiotic use in hospitals, one needs to target the continued need for antibiotics as more diagnostic information becomes available. UK Department of Health guidance promotes an initiative called 'Start Smart then Focus': early effective antibiotics followed by active 'review and revision' 24-72 h later. However in 2017, < 10% of antibiotic prescriptions were discontinued at review, despite studies suggesting that 20-30% of prescriptions could be stopped safely. METHODS/DESIGN Antibiotic Review Kit for Hospitals (ARK-Hospital) is a complex 'review and revise' behavioural intervention targeting healthcare professionals involved in antibiotic prescribing or administration in inpatients admitted to acute/general medicine (the largest consumers of non-prophylactic antibiotics in hospitals). The primary study objective is to evaluate whether ARK-Hospital can safely reduce the total antibiotic burden in acute/general medical inpatients by at least 15%. The primary hypotheses are therefore that the introduction of the behavioural intervention will be non-inferior in terms of 30-day mortality post-admission (relative margin 5%) for an acute/general medical inpatient, and superior in terms of defined daily doses of antibiotics per acute/general medical admission (co-primary outcomes). The unit of observation is a hospital organisation, a single hospital or group of hospitals organised with one executive board and governance framework (National Health Service trusts in England; health boards in Northern Ireland, Wales and Scotland). The study comprises a feasibility study in one organisation (phase I), an internal pilot trial in three organisations (phase II) and a cluster (organisation)-randomised stepped-wedge trial (phase III) targeting a minimum of 36 organisations in total. Randomisation will occur over 18 months from November 2017 with a further 12 months follow-up to assess sustainability. The behavioural intervention will be delivered to healthcare professionals involved in antibiotic prescribing or administration in adult inpatients admitted to acute/general medicine. Outcomes will be assessed in adult inpatients admitted to acute/general medicine, collected through routine electronic health records in all patients. DISCUSSION ARK-Hospital aims to provide a feasible, sustainable and generalisable mechanism for increasing antibiotic stopping in patients who no longer need to receive them at 'review and revise'. TRIAL REGISTRATION ISRCTN Current Controlled Trials, ISRCTN12674243 . Registered on 10 April 2017.
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Affiliation(s)
- Ann Sarah Walker
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Eric Budgell
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Magda Laskawiec-Szkonter
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Katy Sivyer
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
| | - Sarah Wordsworth
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Jack Quaddy
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Marta Santillo
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
| | - Adele Krusche
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
| | - Laurence S. J. Roope
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Nicole Bright
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Fiona Mowbray
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
| | - Nicola Jones
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Kieran Hand
- University of Southampton, Southampton, UK
- University Hospital Southampton NHS Trust, Southampton, UK
| | - Najib Rahman
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Melissa Dobson
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Emma Hedley
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Derrick Crook
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | | | - F. D. Richard Hobbs
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Chris Butler
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Susan Hopkins
- Royal Free London NHS Foundation Trust, London, UK
- National Infection Service, Public Health England, London, UK
| | - Lucy Yardley
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
- School of Psychological Science, University of Bristol, Clifton, UK
| | - Timothy E. A. Peto
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - on behalf of the ARK trial team
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- University of Southampton, Southampton, UK
- University Hospital Southampton NHS Trust, Southampton, UK
- St George’s, University of London, London, UK
- Southern Health NHS Foundation Trust, Southampton, UK
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- The Nuffield Trust, London, UK
- Royal Free London NHS Foundation Trust, London, UK
- School of Psychological Science, University of Bristol, Clifton, UK
- National Infection Service, Public Health England, London, UK
- Brighton and Sussex Medical School, Brighton, UK
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17
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Golding SE, Ogden J, Higgins HM. Shared Goals, Different Barriers: A Qualitative Study of UK Veterinarians' and Farmers' Beliefs About Antimicrobial Resistance and Stewardship. Front Vet Sci 2019; 6:132. [PMID: 31106216 PMCID: PMC6494936 DOI: 10.3389/fvets.2019.00132] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 04/09/2019] [Indexed: 01/21/2023] Open
Abstract
Although much research has investigated the drivers of inappropriate antimicrobial prescribing in human medicine, equivalent research in veterinary medicine is in its infancy. This qualitative study used a critical incident approach to explore farm veterinarians' (vets) and farmers' beliefs about antimicrobial use and antimicrobial stewardship. Semi-structured interviews were conducted with 13 vets and 12 farmers in the UK, who worked mostly with beef cattle, dairy cattle and sheep, but a minority also worked with pigs or poultry. An inductive thematic analysis was conducted to explore how vets and farmers understood their responsibilities toward stewardship and antimicrobial resistance (AMR) and to identify key similarities and differences between the professions. The analysis generated four themes: "A shared conflict between ideals and behaviour," "Barriers to stewardship: the vets' perspective," "Barriers to stewardship: the farmers' perspective," and "A shared ambivalence: ownership vs. other-blaming." Vets and farmers demonstrated good understanding of stewardship but their treatment decisions are not always aligned to stewardship principles. Various barriers to improving antimicrobial stewardship were discussed by vets and farmers, but they placed differing emphasis on specific barriers. Faced with these barriers and an awareness that antimicrobial usage is not always aligned to stewardship principles, vets and farmers expressed frustration and a sense of ambivalence toward stewardship, and also engaged in other-blaming for the problem of AMR. In conclusion, vets and farmers in this study seem motivated to be antimicrobial stewards but feel challenged by the day-to-day reality of their jobs; they experience ambivalence toward their responsibilities for AMR, which may negatively impact their motivation to always act as antimicrobial stewards. Successfully tackling AMR will require change at the individual-, group-, and societal-level. Future interventions to improve antimicrobial usage in livestock farming could be situated within a social ecological framework, where other-blaming between professions is seen as a result of the interplay between psychological and contextual factors. Other-blaming could be reduced using a social identity approach; a common ingroup identity could be created by encouraging vets and farmers to focus on their common goal, namely a shared desire to promote animal welfare through optimal antimicrobial stewardship.
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Affiliation(s)
- Sarah E. Golding
- Faculty of Health & Medical Sciences, School of Psychology, University of Surrey, Guildford, United Kingdom
| | - Jane Ogden
- Faculty of Health & Medical Sciences, School of Psychology, University of Surrey, Guildford, United Kingdom
| | - Helen M. Higgins
- Institute of Veterinary Science, University of Liverpool, Neston, United Kingdom
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