What does antimicrobial stewardship look like where you are? Global narratives from participants in a massive open online course

Power Relations in Optimisation of Therapies and Equity in Access to Antibiotics (PROTEA) Study: investigating the intersection of socio-economic and cultural drivers on antimicrobial resistance (AMR) and its influence on healthcare access and health-providing behaviours in India and South Africa

Across social structures within society, including healthcare, power relations manifest according to gender, socioeconomic status, race, ethnicity, and class influencing infection related healthcare access and health providing-behaviours. Therefore, accounting for sociocultural drivers, including gender, race, and class, and their influence on economic status can improve healthcare access and health-providing behaviours in infection prevention and control (IPC) as well as antibiotic use, which in turn helps mitigate the spread of antimicrobial resistance (AMR). This Wellcome funded research will investigate how and why the social determinants of health and economic status influence how people seek, experience, and provide healthcare for suspected or proven (bacterial) infections and how these factors influence antibiotic prescribing and use in South Africa (upper middle-income country) and India (lower middle-income country). The aim of this body of work is to, (1) define and estimate the sociocultural and economic drivers for AMR in different resource settings, (2) design, implement and evaluate context-sensitive IPC and antimicrobial stewardship (AMS) interventions, and (3) inform policy and strategy for AMR mitigation. The population will be healthcare workers (HCWs), patients, and their carers across acute medical and surgical pathways where IPC and antibiotic-related healthcare access and health-providing behaviours will be studied. Qualitative methods will include ethnographic research, semi-structured in-depth interviews, and focus groups with healthcare providers, patients and carers. Quantitative analysis of bedside observational data from hospitals and population level data on antibiotic use will study the various predictors of AMR using bivariable and multivariable regression analyses. The research will provide high-quality evidence on how social determinants intersect with health, social well-being, and vulnerability in IPC practices and antibiotic use. Using this knowledge we will: 1) design, implement, and measure effects of interventions accounting for these factors; 2) provide a toolkit for advocacy for actors in AMR, and healthcare to assist them to promote dialogue, including policy dialogue on this issue. This work directly benefits the target population and informs healthcare services and practice across the participating countries with potential for wider translation. The setting will be hospitals in South Africa (middle-income country) and India (lower middle-income country). The population will be healthcare workers (HCWs), patients, and their carers across acute medical and surgical pathways where IPC and antibiotic-related health-seeking and health-providing behaviours will be studied. These populations represent communities most affected by infections and AMR because existing interventions do not address a) differences in how surgical versus medical teams manage infections; b) the role of the wider social network of individuals on their decision-making, c) intersection of the social determinants of health including race, gender, socioeconomic deprivation with AMR.

Assessment of challenges and opportunities in antibiotic stewardship program implementation in Northwest Ethiopia

Background

Indiscriminate use of antibiotics leads to antibiotic resistance (AMR) and results in mortality, morbidity, and financial burden. Antibiotic stewardship programs (ASPs) with education can resolve a number of barriers recognized in the implementation of successful ASPs. The aim of this study was to assess health professionals' perceptions and status of ASPs in hospitals in 2022.

Methods

A cross-sectional study was conducted from September 1, 2022 to October 30, 2022. A total of 181 health professionals were included, and a self-administered questionnaire was used to collect data. The status of hospitals was assessed using a checklist. The data were analyzed using SPSS version 23, and descriptive statistics and Chi-square tests (X2) at a P-value of <0.05 were used.

Results

Of the 181 respondents, 163 (90.1 %), and 161 (89.0 %) believed that AMR is a significant problem in Ethiopia and globally, respectively. Easy access to antibiotics 155 (85.6 %), and inappropriate use 137 (75.7 %) were perceived as key contributors to AMR. Antibiotics were believed to be prescribed/dispensed without laboratory results 86 (47.5 %), and antibiotic susceptibility patterns were not considered to guide empiric therapy 81 (44.8 %). ASP was believed to reduce the duration of hospital stays and associated costs 137 (75.7 %), and improve the quality of patient care 133 (73.5 %), whereas 151 (83.4 %), 143 (79 %), and 142 (78.5 %) suggested education, institutional guidelines, and prospective audits with feedback interventions to combat AMR in their hospitals, respectively. There were significant differences in perception among professionals based on professional category and attempts by hospitals to implement ASPs. Although ASPs were not functioning according to standard, there have been attempts to implement it in three hospitals. The issue of ASP had never been heard in general hospitals. Currently, it is feasible to implement ASPs in four hospitals.

Conclusion

The status of ASP in hospitals was very poor. Despite a lack of prior knowledge on ASPs, most respondents do have a positive perception of AMR and the implementation of ASPs. Pharmacist-led prospective audits and feedback with education and institutional guidelines for empiric antibiotic use can be better implemented in hospitals. Involvement of representatives from infection prevention and control, and collaboration among hospitals in ASP implementation will help establish a strong ASP in the area.

Pharmacist roles in antimicrobial stewardship: a qualitative study from India, South Africa and the United Kingdom

Objective

To explore pharmacist roles in antimicrobial stewardship (AMS) in India, South Africa (SA), United Kingdom (UK) and the factors that contribute to their participation in the programme in these countries.

Methods

Data were collected between April 2019 and March 2022 through semi-structured interviews with key AMS stakeholders from India (Kerala); SA (Western Cape province) and the UK (England). Interviews were conducted face to face or via Zoom and Skype platforms, audio recordings were transcribed verbatim and thematically analysed using a grounded theory approach aided by NVivo 12 software.

Results

We interviewed 38 key AMS stakeholders (pharmacists and doctors). India and the UK have dedicated AMS pharmacists (Doctor of Pharmacy and Master of Pharmacy graduates with opportunities for additional post-graduate qualifications respectively). Pharmacists in the UK lead AMS programmes, while in India, predominantly in the private sector, pharmacists drive AMS in collaboration with clinicians. In SA, pharmacists (Bachelor of Pharmacy graduates) participate in AMS out of their own commitment in addition to their pharmacy responsibilities. Private sector pharmacists drive AMS while public sector pharmacists participate in clinician-led AMS programmes. Current pharmacy curricula do not provide adequate training in AMS, and this limitation shapes pharmacist roles and acceptance in AMS among clinicians in India and SA. Support of mentors (doctors/senior pharmacists) and self-motivated learning are key factors for effective pharmacist involvement in AMS.

Conclusions

A contextually developed, standardized and accessible AMS training programme along with pharmacy curricula modification to include AMS, may facilitate prominent pharmacist roles in AMS.

Antibiotic Stewardship in Surgical Departments

Antimicrobial resistance (AMR) has emerged as one of the leading public health threats of the 21st century. New evidence underscores its significance in patients' morbidity and mortality, length of stay, as well as healthcare costs. Globally, the factors that contribute to antimicrobial resistance include social and economic determinants, healthcare governance, and environmental interactions with impact on humans, plants, and animals. Antimicrobial stewardship (AS) programs have historically overlooked surgical teams as they considered them more difficult to engage. This review aims to summarize the evolution and significance of AS in surgical wards, including the surgical intensive care unit (SICU) and the role of diagnostic stewardship (DS). The contribution of AS team members is presented. The new diagnostic modalities and the new technologies including artificial intelligence (AI) are also reviewed.

Optimizing infection control and antimicrobial stewardship bedside discussion: a scoping review of existing evidence on effective healthcare communication in hospitals

BACKGROUND

The link between healthcare worker (HCW) communication, teamwork and patient safety is well-established. Infection prevention and control (IPC) and antimicrobial stewardship (AMS) require multidisciplinary teamwork and communication.

OBJECTIVES

We conducted a scoping review of published evidence on effective mechanisms of HCW team communication in hospitals with the intention of transferring and tailoring learning to IPC and AMS team communication.

METHODS

PubMed, Scopus, Web of Science, and CINAHL were searched for studies that investigated HCW team communication across in-hospital patient pathways. Studies published between 2000 and 2021 that provided evidence on/or described the effect of communication on team and patient outcomes in hospital were included. Through a process of inductive qualitative content analysis, key themes in the included studies were identified.

RESULTS

Of 537 studies identified, 53 (from high-income countries) were included in the data extraction. Fifty one percent (27/53) of studies were conducted in high acuity settings e.g., intensive care units. Standardizing or structuring the content and/or process of team communication was the most common goal of interventions (34/53, 64%). The key outcome measures were either team communication focused (25/34,74%) or patient and process outcome focused (8/34, 24%), such as reduced length of mechanical ventilation days, length of hospital stay, and shorter empiric antibiotic duration. Four studies (4/53, 8%) associated improved communication with positive IPC and AMS outcome measures. Mixed method intervention studies primarily facilitated collaborative input from HCWs and applied structures to standardize the content of patient care discussions, whereas observational studies describe component of team communication.

CONCLUSIONS

A communication strategy that formalizes input from multidisciplinary team members can lead to optimized and consistent clinical discussion including in IPC and AMS-related care. Although we were unable to assess the effectiveness of interventions, the existing evidence suggests that optimizing team communication can have a positive effect on infection-related patient outcomes.

Mentorship as an overlooked dimension of research capacity strengthening: how to embed value-driven practices in global health

Mentorship in global health remains an overlooked dimension of research partnerships. Commitment to effective mentorship models requires value-driven approaches. This includes having an understanding of (1) what mentorship means across different cultural and hierarchical boundaries in the health research environment, and (2) addressing entrenched power asymmetries across different aspects including funding, leadership, data and outputs, and capacity strengthening. Existing guidance towards equity and sustainability fails to inform how to navigate complex relationships which hinder effective mentorship models. We focus this perspective piece on human capacity strengthening in research partnerships through mentorship. Using a case study of a research partnership, we describe the lessons learnt and the challenges faced in the mentor mentee relationship while maintaining an effective and sustainable partnership. Human capacity strengthening must research projects and collaborations, and recognise local leadership and ownership. To be transformative and effective, practices need to be driven by common values across research teams.

Nursing experiences in antimicrobial optimisation in the intensive care unit: A convergent analysis of a national survey

BACKGROUND

Recent evidence highlights the need for an interdisciplinary approach to antimicrobial stewardship (AMS). Nursing involvement in optimising antimicrobials in the intensive care unit (ICU) remains understudied.

OBJECTIVE

The objective of this study was to explore nurses' perceptions and experiences of antimicrobial optimisation or stewardship in ICUs in Australia.

METHODS

An anonymous web-based survey was deployed nationally in early 2021 through two ICU nursing networks. Associations between survey responses were analysed descriptively and by using nonparametric tests (with statistical significance established at p ≤ 0.05). Free-text survey responses underwent qualitative thematic analysis. Interpretation and reporting of quantitative and qualitative data were integrated.

RESULTS

A total of 226 ICU nurses completed the survey. The majority (197/226; 87%) responded that lack of education limits engagement in AMS. Only 13% (30/226) reported the presence of AMS education and training for nurses in their ICUs. Only about half (108/226; 48%) of the nurses were confident to question prescribers when they considered that the antimicrobial prescribed was unnecessary, with nurses in senior roles more likely to do so than nurses providing bedside care (p < 0.05). Gaps in education (including unfamiliarity with AMS roles), noninclusive antimicrobial discussions, moral distress, and potential workload burden were seen as potential barriers/challenges to engagement.

CONCLUSION

The multifactorial barriers identified that inhibit nurses from performing AMS tasks could be addressed by strengthening interprofessional education at all levels and by applying practical AMS interventions that are inclusive for nursing participation. A purposeful culture change that fosters psychological safety and collaborative practice is paramount to supporting nurses in these roles.

Experiences of antibiotic use among Brazilian healthcare users: An exploratory study

INTRODUCTION

This article analyzes experiences of antibiotic use and bacterial infections among Primary Health Care users of the Brazilian Unified Health System (SUS) and the possible implications for antimicrobial resistance (AMR). The aim is to map aspects that shape users' lay knowledge regarding antibiotics use and AMR.

METHODS

This is an exploratory study, which consists primarily of individual in-depth interviews with 19 respondents. Recurrent interview topics were coded and analysed according to thematic content analysis.

RESULTS

Our findings show users' lived experiences constitute three dimensions related to users' previous antibiotic use: (1) lay knowledge about medicines; (2) previous bacterial infections and (3) communication during the consultation. Lay knowledge encompasses the users' understanding of how antibiotics work in comparison to other drugs and experimentations they make with medication. Users' narratives about bacterial infections are divided into situations of urinary tract infections and antibiotic treatments for other conditions. Communication during the consultation is mainly characterized by a lack of shared knowledge and trust in the doctor-patient relationship.

DISCUSSION

Users bring together knowledge learned from their own experiences to create the rationale, which shapes how they understand antibiotic use, bacterial infections and medical advice. These experiences are interwoven with information received from healthcare professionals (HPs) on these topics, creating a scenario that goes beyond professional information about antibiotic use. Users have knowledge about medication, antibiotics use and bacterial infection but do not have room to share it with HP, allowing lived experiences to take precedence over professional information.

CONCLUSION

Users ascribe symbolic meanings to antibiotics creating a lay knowledge frame, even if this knowledge is not scientifically correct. The personal experiences of bacterial infections and their treatment are also an important source of knowledge about antibiotic use and AMR among users. Users demand from their HPs both trust and willingness to listen to their health narratives and experiences. By considering lay knowledge as part of the assessment of a user's health condition, rather than dismissing it as erroneous and therefore unworthy of attention, HPs may enhance the compliance of users.

PATIENT OR PUBLIC CONTRIBUTION

Patients or community members did not participate in the design stage of the study. Primary Care patients were invited to participate as respondents of in-depth interviews, which were carried out by the first author at a Primary Care Unit (PCU) in the suburb of Campo Limpo, Southern region of São Paulo, Brazil. Patients were interviewed after reading and signing a Free and Informed Consent Form, holding with them a copy of the Form. Among the final activities of the project, a feedback session at the same PCU is planned to report on the results of the study. All respondents will have the opportunity to contribute further information regarding their antibiotic use and exchange knowledge and experiences on antimicrobial resistance.

Learning Design Strategies in MOOCs for Physicians' Training: A Scoping Review

In recent years, there has been an increased implementation of massive open online courses (MOOCs). This teaching model plays a pivotal role in online education because it can provide high-quality learning resources to numerous students with great feasibility, shaping training courses according to their different learning requirements. Although the widespread adoption of MOOCs in medical education has led to numerous benefits for undergraduate and graduate doctors, their role remains unclear, suggesting the need to analyze the key factors of such a learning method in this field. To achieve this aim, a scoping review, in line with the PRISMA method for qualitative synthesis, was performed by considering studies published from 2016 to 2021, written in English, and including the physician population. Through this literature analysis, the following main areas of interest came to light: (1) pedagogical approaches, (2) MOOC structure-related variables, (3) participant-related variables, and (4) MOOCs vs. traditional courses. The review provides valuable evidence on factors underlying MOOCs effectiveness, which might be helpful for academic and healthcare organizations in designing effective training courses for physicians.

Tailoring Antimicrobial Stewardship (AMS) Interventions to the Cultural Context: An Investigation of AMS Programs Operating in Northern Italian Acute-Care Hospitals

Antibiotic misuse and overuse are important contributors to the development of antimicrobial resistance (AMR). Antimicrobial stewardship (AMS) programs are coordinated sets of actions aiming to promote appropriate antibiotic use, improving patient outcomes whilst reducing AMR. Two main organizational models for AMS programs have been described: restrictive strategies (RS) vs. enabling strategies (ES). Evaluating and understanding social and cultural influences on antibiotic decision-making are critical for the development of successful and sustainable context-specific AMS programs. Characteristics and surrogate outcomes of AMS programs operating in acute-care hospitals of Piedmont in north-western Italy were investigated. The aim of this study was assessing whether RS vs. ES operating in our context were associated with different outcomes in terms of total antimicrobial usage and percentage of methicillin-resistant Staphylococcus aureus (MRSA) and carbapenem-resistant enterobacteria (CRE) over invasive isolates. In total, 24 AMS programs were assessed. ES were more frequently chosen compared to RS, with the latter being implemented only in broader AMS programs involving enabling components (combined strategy, CS). This study found no difference in evaluated outcomes among hospitals implementing ES vs. CS, suggesting both approaches could be equally valid in our context.

Tackling antimicrobial resistance across sub-Saharan Africa: current challenges and implications for the future

INTRODUCTION

Antimicrobial resistance (AMR) is a concern as this increases morbidity, mortality, and costs, with sub-Saharan Africa having the highest rates globally. Concerns with rising AMR have resulted in international, Pan-African, and country activities including the development of national action plans (NAPs). However, there is variable implementation across Africa with key challenges persisting.

AREAS COVERED

Consequently, there is an urgent need to document current NAP activities and challenges across sub-Saharan Africa to provide future guidance. This builds on a narrative review of the literature.

EXPERT OPINION

All surveyed sub-Saharan African countries have developed their NAPs; however, there is variable implementation. Countries including Botswana and Namibia are yet to officially launch their NAPs with Eswatini only recently launching its NAP. Cameroon is further ahead with its NAP than these countries; though there are concerns with implementation. South Africa appears to have made the greatest strides with implementing its NAP including regular monitoring of activities and instigation of antimicrobial stewardship programs. Key challenges remain across Africa. These include available personnel, expertise, capacity, and resources to undertake agreed NAP activities including active surveillance, lack of focal points to drive NAPs, and competing demands and priorities including among donors. These challenges are being addressed, with further co-ordinated efforts needed to reduce AMR.