OUP accepted manuscript

A qualitative analysis of the unwritten rules influencing antibiotic prescribing practices among French poultry veterinarians

Background

It is now recognized that a better understanding of prescriber behaviour is needed to improve antimicrobial stewardship programmes. Most studies conducted in the livestock sector have focused on farmers' perspectives, while the prescribing habits of veterinarians have remained overlooked.

Objective

Our study explored the psychosocial determinants associated with antibiotic prescribing practices in the French poultry sector by analysing the informal norms and unwritten rules that influence veterinarians' prescribing decisions.

Methods

A qualitative study was conducted in four French regions in February 2021. Using the biographical narrative interpretive method, semi-structured interviews were conducted with 16 poultry veterinarians with varying professional experience. Three main themes were retained for data analysis: (i) compliance with and deviations from prescribing recommendations, (ii) the influence of fellow veterinarians on antibiotic decisions and (iii) the key role of veterinary corporate groups.

Results

When prescribing antibiotics, junior veterinarians were strongly influenced by senior veterinarians who acted as role models driving clinical practices. Prescribing habits were shared through peer networks in which veterinarians participated throughout their careers. Finally, veterinary corporate groups helped to shape veterinarians' prescribing habits by promoting existing guidelines and even producing in-house recommendations.

Conclusions

We show that, in parallel with official guidelines, prescribing habits circulate among veterinarians and are shared in professional circles. Therefore, antimicrobial stewardship interventions should focus not only on official guidelines and communication channels, but also unwritten professional rules and organizations influencing veterinarians' prescribing practices.

Community antibiotic consumption and associated factors in Lusaka district of Zambia: findings and implications for antimicrobial resistance and stewardship

Introduction

Antimicrobial resistance (AMR) is a global public health crisis. This study assessed the general public's consumption of antibiotics and associated factors in the Lusaka district of Zambia.

Methods

This cross-sectional study was conducted among 2038 participants between December 2022 and January 2023. Data were analysed using Stata 13.0. Multivariable regression techniques were used to determine the factors that influenced antibiotic consumption.

Results

Of the 2038 participants, 53.4% were female, and 51.5% had attended at least secondary school. Antibiotic use was 99.2%, of which 40.9% were appropriately used. Overall, 79.1% of antibiotics were prescribed in hospitals, while 20.9% were used from leftovers and accessed without prescriptions. This study found that the appropriate use of antibiotics was associated with being female, being aged 35 years and above, attaining secondary school or tertiary education, having a monthly expenditure of 195 USD and above, being aware that antibiotics were not the same as painkillers, and being confident that when someone was hospitalized, they would get well.

Conclusions

This study found that the appropriate use of antibiotics was low, and this is an urgent public health issue requiring community engagement in tackling AMR and adherence to treatment guidelines in healthcare facilities. Additionally, there is a need to implement and strengthen antimicrobial stewardship programmes in healthcare facilities to promote the rational use of antibiotics in Zambia. There is also a need to heighten community awareness campaigns and educational activities on the appropriate use of antibiotics.

Antimicrobial stewardship: knowledge, attitudes and practices regarding antimicrobial use and resistance among non-healthcare students at the University of Zambia

Background

Antimicrobial resistance (AMR) poses a significant threat to the world and could become humanity's next major challenge. This study assessed non-healthcare students' knowledge, attitude and practices (KAP) towards antimicrobial use (AMU) and AMR at the University of Zambia.

Methods

This cross-sectional study was conducted among 443 non-healthcare students from August to October 2022 using a structured questionnaire. Data analysis was done using IBM SPSS version 24.0.

Results

Of the 433 participants, 55.2%, 63.5% and 45% had moderate KAP scores regarding AMU and AMR. The prevalence of self-medication with antibiotics was 76.7%. Male participants were less likely to have good knowledge (OR = 0.524, 95% CI: 0.347-0.792) and positive attitudes (OR = 0.585, 95% CI: 0.364-0.940) towards AMU and AMR compared with females. Students who were studying Engineering and Mining were more likely to have good knowledge of AMR (OR = 1.891, 95% CI: 1.197-2.987) compared with those in Social Sciences. Those who were in their fourth and fifth years were more likely to have positive attitudes towards AMU and AMR (OR = 1.851, 95% CI: 1.147-2.986) compared with those who were in the first, second and third years. Finally, students who practised self-medication were less likely to have good self-reported practice towards AMR (OR = 0.442, 95% CI: 0.278-0.702) compared with those who did not.

Conclusions

This study demonstrated that non-healthcare students had moderate KAP regarding AMU and AMR. All university students should be provided with education about AMU and AMR through free short courses, seminars, workshops, and AMR and antimicrobial stewardship awareness campaigns.

GPs' Perspective on a Multimodal Intervention to Enhance Guideline-Adherence in Uncomplicated Urinary Tract Infections: A Qualitative Process Evaluation of the Multicentric RedAres Cluster-Randomised Controlled Trial

Urinary tract infections (UTIs) are among the most common reasons patients seeking health care and antibiotics to be prescribed in primary care. However, general practitioners' (GPs) guideline adherence is low. The RedAres randomised controlled trial aims to increase guideline adherence by implementing a multimodal intervention consisting of four elements: information on current UTI guidelines (1) and regional resistance data (2); feedback regarding prescribing behaviour (3); and benchmarking compared to peers (4). The RedAres process evaluation assesses GPs' perception of the multimodal intervention and the potential for implementation into routine care. We carried out 19 semi-structured interviews with GPs (intervention arm). All interviews were carried out online and audio recorded. For transcription and analysis, Mayring's qualitative content analysis was used. Overall, GPs considered the interventions helpful for knowledge gain and confirmation when prescribing. Information material and resistance were used for patient communication and teaching purposes. Feedback was considered to enhance reflection by breaking routines of clinical workup. Implementation into routine practice could be enhanced by integrating feedback loops into patient management systems and conveying targeted information via trusted channels or institutions. The process evaluation of RedAres intervention was considered beneficial by GPs. It confirms the convenience of multimodal interventions to enhance guideline adherence.

Impact of the COVID-19 pandemic on antimicrobial stewardship support for general practices in England: a qualitative interview study

BACKGROUND

In England, clinical commissioning group (CCG; now replaced by Integrated Care Systems [ICSs]) and primary care network (PCN) professionals support primary care prescribers to optimise antimicrobial stewardship (AMS).

AIM

To explore views and experiences of CCG and PCN staff in supporting AMS, and the impact of COVID-19 on this support.

DESIGN & SETTING

Qualitative interview study in primary care in England.

METHOD

Semi-structured interviews with staff from CCG and PCNs responsible for AMS were conducted at two timepoints via telephone. These were audio-recorded, transcribed, and analysed thematically.

RESULTS

Twenty-seven interviews were conducted with 14 participants (nine CCG, five PCN) in December 2020-January 2021 and February-May 2021. The study found that AMS support was (1) deprioritised in order to keep general practice operational and deliver COVID-19 vaccines; (2) disrupted as social distancing made it harder to build relationships, conduct routine AMS activities, and challenge prescribing decisions; and (3) adapted, with opportunities identified for greater use of technology and changing patient and public perceptions of viruses and self-care. It was also found that resources to support AMS were valued if they were both novel, to counter AMS 'fatigue', and sufficiently familiar to fit with existing and/or future AMS.

CONCLUSION

AMS needs to be reprioritised in general practice in the post-pandemic era and within the new ICSs in England. This should include interventions and strategies that combine novel elements with already familiar strategies to refresh prescribers' motivation and opportunities for AMS. Behaviour change interventions should be aimed at improving the culture and processes for how PCN pharmacists voice concerns about AMS to prescribers in general practice and take advantage of the changed patient and public perceptions of viruses and self-care.

Antimicrobial Resistance in the Global Health Network: Known Unknowns and Challenges for Efficient Responses in the 21st Century

Antimicrobial resistance (AMR) is one of the Global Health challenges of the 21st century. The inclusion of AMR on the global map parallels the scientific, technological, and organizational progress of the healthcare system and the socioeconomic changes of the last 100 years. Available knowledge about AMR has mostly come from large healthcare institutions in high-income countries and is scattered in studies across various fields, focused on patient safety (infectious diseases), transmission pathways and pathogen reservoirs (molecular epidemiology), the extent of the problem at a population level (public health), their management and cost (health economics), cultural issues (community psychology), and events associated with historical periods (history of science). However, there is little dialogue between the aspects that facilitate the development, spread, and evolution of AMR and various stakeholders (patients, clinicians, public health professionals, scientists, economic sectors, and funding agencies). This study consists of four complementary sections. The first reviews the socioeconomic factors that have contributed to building the current Global Healthcare system, the scientific framework in which AMR has traditionally been approached in such a system, and the novel scientific and organizational challenges of approaching AMR in the fourth globalization scenario. The second discusses the need to reframe AMR in the current public health and global health contexts. Given that the implementation of policies and guidelines are greatly influenced by AMR information from surveillance systems, in the third section, we review the unit of analysis ("the what" and "the who") and the indicators (the "operational units of surveillance") used in AMR and discuss the factors that affect the validity, reliability, and comparability of the information to be applied in various healthcare (primary, secondary, and tertiary), demographic, and economic contexts (local, regional, global, and inter-sectorial levels). Finally, we discuss the disparities and similarities between distinct stakeholders' objectives and the gaps and challenges of combatting AMR at various levels. In summary, this is a comprehensive but not exhaustive revision of the known unknowns about how to analyze the heterogeneities of hosts, microbes, and hospital patches, the role of surrounding ecosystems, and the challenges they represent for surveillance, antimicrobial stewardship, and infection control programs, which are the traditional cornerstones for controlling AMR in human health.

Family doctors' roles and perceptions on antibiotic consumption and antibiotic resistance in Romania: a qualitative study

BACKGROUND

Antimicrobial resistance (AMR) is a major global health issue, bringing significant health burden and costs to societies. Increased antibiotic consumption (ABC) is linked to AMR emergence. Some of the known drivers of ABC are antibiotics over-prescription by physicians and their misuse by patients. Family doctors are recognised as important stakeholders in the control of ABC as they prescribe antibiotics and are considered a reliable source of medical information by patients. Therefore, it is important to explore their perceptions, especially in Romania, which has the highest ABC among European Union Member States. Furthermore, there is no published research exploring Romanian family doctors' perceptions regarding this phenomenon.

METHODS

This was a qualitative study with data collection via semi-structured interviews among 12 family doctors. Manifest and latent content analysis was used to gain an in-depth understanding of their perceptions. Findings were mapped onto the domains of the Behaviour Change Wheel to facilitate a theory driven systematization and analysis.

RESULTS

Two main subthemes emerged: i) factors affecting ABC and prescribing and ii) potential interventions to tackle ABC and antibiotic resistance. The factors were further grouped in those that related to the perceived behaviour of family doctors or patients as well as those that had to do with the various systems, local contexts and the COVID-19 pandemic. An overarching theme: 'family doctors in Romania see their role differently when it comes to antibiotic resistance and perceive the lack of patient education or awareness as one of the major drivers of ABC' was articulated. The main findings suggested that the perceived factors span across the capability, opportunity and motivational domains of the behaviour change wheel and could be addressed through a variety of interventions - some identified by the participants. Findings can also be viewed through cultural lenses which shed further light on the family doctor- patient dynamic when it comes to antibiotics use.

CONCLUSION

Potential interventions to tackle identified factors emerged, revolving mostly on efforts to educate patients or the public. This exploratory research provides key perspectives and facilitates further research on potential interventions to successfully address AMR in Romania or similar settings.

How to design and implement an outpatient antimicrobial stewardship programme

Antimicrobial stewardship programmes in the outpatient setting have recently become an area of focus in an effort to improve antimicrobial prescribing. The Centers for Disease Control and Prevention and The Joint Commission have recently addressed this concern and provided a framework for the implementation of an outpatient stewardship programme. This manuscript offers detailed guidance on how to design and implement an outpatient antimicrobial stewardship programme and reviews the literature on current strategies. Challenges related to initiating and maintaining outpatient stewardship efforts are also discussed. This article is part of the Antibiotic stewardship Special Issue: https://www.drugsincontext.com/special_issues/antimicrobial-stewardship-a-focus-on-the-need-for-moderation.

Psychological and cultural factors influencing antibiotic prescription

Humans have inundated the environment worldwide with antimicrobials for about one century, giving selective advantage to antibiotic-resistant bacteria. Therefore, antibiotic resistance has become a public health problem responsible for increased mortality and extended hospital stays because the efficacy of antibiotics has diminished. Hospitals and other clinical settings have implemented stewardship measures to reduce antibiotic administration and prescription. However, these measures demand multifactorial approaches, including multidisciplinary teams in clinical settings and the education of professionals and patients. Recent studies indicate that individual factors, such as mother-infant attachment and parenting styles, play a critical role in antibiotic use. Also, macrocontextual factors, such as economic, social, or cultural backgrounds, may impact antibiotic use rates. Therefore, research aiming to ameliorate stewardship measures must include psychologically and sociologically based research.

Going local: Evaluating guideline adherence and appropriateness of antibiotic prescribing in patients with febrile neutropenia at an academic teaching hospital

Background

Febrile neutropenia (FN) is a medical emergency with significant morbidity and mortality for oncology patients, requiring comprehensive workup and timely antibiotic administration. We evaluated concordance with locally developed FN guidelines and outcomes of cancer patients admitted to general internal medicine at an academic teaching hospital.

Methods

We conducted a retrospective observational cohort study of patients admitted between July 1, 2016, and June 30, 2017, for FN. Patients were classified as having low-risk or high-risk FN according to their malignancy and chemotherapy. Primary outcome was the proportion of patients receiving guideline-concordant antibiotics within 48 hours of admission to general internal medicine. Secondary outcomes were the proportion of patients in whom empirical antibiotics were active against pathogens isolated, rate of antibiotic-associated adverse events, and in-hospital mortality. We used logistic regression to model relationship between FN risk and guideline-concordant antibiotics.

Results

Among 100 patients included, 34 (34%) were low-risk FN and 66 (66%) were high-risk. Proportion of guideline-concordant empirical antibiotics was significantly lower among low-risk FN patients than high-risk patients: 12 (35%) of 34 versus 47 (71%) of 66 (P = .001). Empirical antibiotics were active against 17 (94%) of 18 isolated pathogens. The mortality rate was 3%, and 16% of patients experienced antibiotic-associated adverse events. Hematological malignancy and infectious diseases-trained physician involvement were associated with guideline-concordant prescribing, with adjusted odds ratios of 3.76 (95% CI, 1.46-9.70; P = .006) and 3.71 (95% CI, 1.49-9.23; P = .005), respectively.

Conclusions

Guideline concordance was low compared to published reports. Factors influencing appropriate antimicrobial prescribing in patients with FN warrant further exploration.

OUP accepted manuscript

In order to design appropriate antimicrobial stewardship (AMS) programmes, it is crucial to understand challenges to tackling antibiotic resistance (AMR) specific to each healthcare setting. Antibiotic prescribing in primary care accounts for most prescriptions with a significant proportion considered clinically inappropriate. Qualitative research has a long history in social sciences, but its value and contribution are still contested in medical journals including in the AMR/AMS field. However, through its focus on understanding, meaning making and explaining, qualitative research can offer insights in how to improve AMS efforts in primary care. This paper provides an overview of unique considerations, contributions and challenges related to using qualitative research in AMS to help the AMS community new to qualitative research to utilize its potential most fully. First, we discuss specific considerations for AMS in relation to the stages of conducting a qualitative study, including identifying a research question and choosing a suitable methodology; sampling appropriate participants; planning a recruitment strategy; choosing a method of data collection; and conducting data analysis. These are illustrated with examples of qualitative AMS studies in primary care. Second, we highlight the importance of patient and public involvement throughout all stages of the project and ensuring quality in qualitative AMS research. Finally, drawing on these considerations, we make a further case for the value and contribution of qualitative methodologies in AMS/AMR research while outlining future directions for both AMS and qualitative research, including the need for studies with diverse actors; interdisciplinary collaborations; and complex decisions on methodologies and timelines.