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Wasson MK, Luther VP, Armstrong WS, Schwartz BS, Shnekendorf R, Logan A, Bennani K, Spicer JO. Skills, Not Just Knowledge: Infectious Diseases Fellows' Recommendations Regarding Antimicrobial Stewardship Training. Clin Infect Dis 2023; 77:1265-1272. [PMID: 37310036 DOI: 10.1093/cid/ciad358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/23/2023] [Accepted: 06/08/2023] [Indexed: 06/14/2023] Open
Abstract
BACKGROUND Antimicrobial stewardship (AS) is an important topic in infectious diseases (ID) training, yet many ID fellowships lack formal training, and little is known about fellows' learning preferences. METHODS We conducted 24 in-depth interviews with ID fellows across the United States during 2018 and 2019 to explore their experiences with and preferences for AS education during fellowship. Interviews were transcribed, deidentified, and analyzed to identify themes. RESULTS Fellows had variable exposure to AS before and during fellowship, which impacted their knowledge about and attitude toward stewardship as a career; however, all fellows expressed the importance of learning general stewardship principles during fellowship. Some fellows' training included mandatory stewardship lectures and/or rotations, but most fellows felt their primary stewardship learning occurred through informal experiences in the clinical setting, such as holding the antimicrobial approval pager. Fellows expressed a preference for a standardized, structured curriculum that included in-person practical, interactive discussions with multidisciplinary faculty along with the opportunity to practice and apply their skills; however, they emphasized that time needed to be set aside for those educational activities. Although they wanted to learn the evidence and rationale for stewardship recommendations, they especially wanted training in and feedback on how to communicate stewardship recommendations to other health professionals, particularly in the setting of conflict. CONCLUSIONS ID fellows believe that standardized AS curricula should be included in their fellowship training, and they prefer structured, practical, and interactive learning experiences.
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Affiliation(s)
- Megan K Wasson
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - Vera P Luther
- Division of Infectious Diseases, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Wendy S Armstrong
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Brian S Schwartz
- Division of Infectious Diseases, Department of Medicine, University of California, San Francisco, California, USA
| | | | - Ashleigh Logan
- Infectious Diseases Society of America, Arlington, Virginia, USA
| | - Kenza Bennani
- Infectious Diseases Society of America, Arlington, Virginia, USA
| | - Jennifer O Spicer
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
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Burton E, O’Driscoll M, Fleming A. The protected antimicrobial process in a University Teaching Hospital: a qualitative interview study exploring the knowledge, attitudes, and experiences of healthcare professionals. Int J Clin Pharm 2022; 44:630-640. [PMID: 35124762 PMCID: PMC9200682 DOI: 10.1007/s11096-022-01381-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 01/21/2022] [Indexed: 11/05/2022]
Abstract
AbstractBackground The protected or restricted supply of certain antimicrobials such as linezolid, caspofungin, aztreonam, in the acute hospital setting is an important element of Antimicrobial Stewardship (AMS) programmes to address the growing problem of antimicrobial resistance. This process involves submitting an application for use to be reviewed typically by a Consultant Microbiologist, Infectious Disease Consultant or Antimicrobial Pharmacist. Aim To investigate healthcare professionals’ knowledge, experiences, and attitudes towards the protected/restricted antimicrobials process in order to identify possible methods of optimisation and improvement. Method Semi-structured interviews with stakeholders involved in the protected/restricted antimicrobial prescribing, dispensing and administration process were conducted in September–October 2019 in a 350-bed voluntary, general, acute hospital in Ireland. Interviews were analysed by the Framework method and mapped to the Theoretical Domains Framework (TDF). Results Interviews were conducted with 8 Doctors, 4 Pharmacists and 3 Nurses. TDF domains identified included: ‘Knowledge’; ‘Social/professional role and identity’; ‘Social influences’; ‘Memory, attention and decision processes’; ‘Beliefs about consequences’; ‘Environmental contexts and resources’. The relationship between prescribers and the AMS Team was reported as a facilitator of the process, whereas the inconsistency of the filing and versions of forms on the wards were seen as challenges. Conclusion The results of this study have shown that the existing protected/restricted antimicrobial process is a multi-disciplinary effort with barriers that require attention in order to make future improvements. Standardization of the form across all wards, an electronic version of the form, and structured education around AMS were suggested to optimize the process.
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OUP accepted manuscript. Clin Infect Dis 2022; 75:1-2. [DOI: 10.1093/cid/ciac286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Indexed: 11/12/2022] Open
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Wojcik G, Ring N, McCulloch C, Willis DS, Williams B, Kydonaki K. Understanding the complexities of antibiotic prescribing behaviour in acute hospitals: a systematic review and meta-ethnography. ACTA ACUST UNITED AC 2021; 79:134. [PMID: 34301332 PMCID: PMC8299683 DOI: 10.1186/s13690-021-00624-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 05/30/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND Antimicrobial resistance poses a serious global public health threat. Hospital misuse of antibiotics has contributed to this problem and evidence-based interventions are urgently needed to change inappropriate prescribing practices. This paper reports the first theoretical stage of a longer-term project to improve antibiotic prescribing in hospitals through design of an effective behaviour-change intervention. METHODS Qualitative synthesis using meta-ethnography of primary studies reporting doctors' views and experiences of antibiotic prescribing in hospitals for example, their barriers to appropriate prescribing. Twenty electronic databases were systematically searched over a 10-year period and potential studies screened against eligibility criteria. Included studies were quality-appraised. Original participant quotes and author interpretations were extracted and coded thematically into NVivo. All study processes were conducted by two reviewers working independently with findings discussed with the wider team and key stakeholders. Studies were related by findings into clusters and translated reciprocally and refutationally to develop a new line-of-argument synthesis and conceptual model. Findings are reported using eMERGe guidance. RESULTS Fifteen papers (13 studies) conducted between 2007 and 2017 reporting the experiences of 336 doctors of varying seniority working in acute hospitals across seven countries, were synthesised. Study findings related in four ways which collectively represented multiple challenges to appropriate antibiotic medical prescribing in hospitals: loss of ownership of prescribing decisions, tension between individual care and public health concerns, evidence-based practice versus bedside medicine, and diverse priorities between different clinical teams. The resulting new line-of-argument and conceptual model reflected how these challenges operated on both micro- and macro-level, highlighting key areas for improving current prescribing practice, such as creating feedback mechanisms, normalising input from other specialties and reducing variation in responsibility for antibiotic decisions. CONCLUSIONS This first meta-ethnography of doctors` experiences of antibiotic prescribing in acute hospital settings has enabled development of a novel conceptual model enhancing understanding of appropriate antibiotic prescribing. That is, hospital antibiotic prescribing is a complex, context-dependent and dynamic process, entailing the balancing of many tensions. To change practice, comprehensive efforts are needed to manage failures in communication and information provision, promote distribution of responsibility for antibiotic decisions, and reduce fear of consequences from not prescribing. TRIAL REGISTRATION PROSPERO registration: CRD42017073740 .
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Affiliation(s)
- Gosha Wojcik
- School of Health and Social Care, Edinburgh Napier University, EH11 4BN, Edinburgh, UK.
| | - Nicola Ring
- School of Health and Social Care, Edinburgh Napier University, EH11 4BN, Edinburgh, UK
| | - Corrienne McCulloch
- Edinburgh Critical Care Research Group, University of Edinburgh, Edinburgh Royal Infirmary, EH16 4SA, Edinburgh, UK
| | - Diane S Willis
- School of Health and Social Care, Edinburgh Napier University, EH11 4BN, Edinburgh, UK
| | - Brian Williams
- School of Health and Social Care, Edinburgh Napier University, EH11 4BN, Edinburgh, UK
| | - Kalliopi Kydonaki
- School of Health and Social Care, Edinburgh Napier University, EH11 4BN, Edinburgh, UK
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Barlam TF. The state of antibiotic stewardship programs in 2021: The perspective of an experienced steward. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2021; 1:e20. [PMID: 36168492 PMCID: PMC9495416 DOI: 10.1017/ash.2021.180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 06/29/2021] [Indexed: 05/05/2023]
Abstract
Recognition of antibiotic stewardship programs (ASPs) as essential components of quality health care has dramatically increased in the past decade. The value of ASPs has been further reinforced during the coronavirus disease 2019 (COVID-19) pandemic because these programs were instrumental in monitoring antibiotic use, assessing emerging COVID-19 therapies, and coordinating implementation of monoclonal antibody infusions and vaccinations. ASPs are now required across hospital settings as a condition of participation for the Centers for Medicare and Medicaid Services and for accreditation by The Joint Commission. In the 2019 National Healthcare Safety Network annual survey, almost 89% of hospitals met the Seven Core Elements for ASPs defined by the Centers for Disease Control and Prevention. More than 61% of programs were co-led by physicians and pharmacists, evidence of the leadership role of both groups. ASPs employ many strategies to improve prescribing. Core interventions of preauthorization for targeted antibiotics, prospective audit and feedback, and development of local treatment guidelines have been supplemented with numerous emerging strategies. Diagnostic stewardship, optimizing duration of therapy, promoting appropriate conversion from intravenous to oral therapy, monitoring at transitions of care and hospital discharge, implementing stewardship initiatives in the outpatient setting, and increasing use of telemedicine are approaches being adopted across hospital settings. As a core function for medical facilities, ASP leaders must ensure that antibiotic use and ASP interventions promote optimal and equitable care. The urgency of success becomes progressively greater as complex patterns of antibiotic resistance continue to emerge, exacerbated by unpredictable factors such as a worldwide pandemic.
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Affiliation(s)
- Tamar F. Barlam
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center, Boston, Massachusetts
- Author for correspondence: Tamar F. Barlam MD, Boston Medical Center, Section of Infectious Diseases, 801 Massachusetts Avenue, 2nd Floor, Boston, MA02118. E-mail:
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Barlam TF, Childs E, Zieminski SA, Meshesha TM, Jones KE, Butler JM, Damschroder LJ, Goetz MB, Madaras-Kelly K, Reardon CM, Samore MH, Shen J, Stenehjem E, Zhang Y, Drainoni ML. Perspectives of Physician and Pharmacist Stewards on Successful Antibiotic Stewardship Program Implementation: A Qualitative Study. Open Forum Infect Dis 2020; 7:ofaa229. [PMID: 32704510 PMCID: PMC7367692 DOI: 10.1093/ofid/ofaa229] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 06/08/2020] [Indexed: 11/14/2022] Open
Abstract
Background Antibiotic stewardship programs (ASPs) are required at every hospital regardless of size. We conducted a qualitative study across different hospital settings to examine perspectives of physician and pharmacist stewards about the dynamics within their team and contextual factors that facilitate the success of their programs. Methods Semistructured interviews were conducted in March-November 2018 with 46 ASP stewards, 30 pharmacists, and 16 physicians, from 39 hospitals within 2 large hospital systems. Results We identified 5 major themes: antibiotic stewards were enthusiastic about their role, committed to the goals of stewardship for their patients and as a public-health imperative, and energized by successful interventions; responsibilities of pharmacist and physician stewards are markedly different, and pharmacy stewards performed the majority of the day-to-day stewardship work; collaborative teamwork is important to improving care, the pharmacists and physicians supported each other, and pharmacists believed that having a strong physician leader was essential; provider engagement strategies are a critical component of stewardship, and recommendations must be communicated in a collegial manner that did not judge the provider competence, preferably through face-to-face interactions; and hospital leadership support for ASP goals and for protected time for ASP activities is critical for success. Conclusions The physician-pharmacist team is essential for ASPs; most have pharmacists leading and performing day-to-day activities with physician support. Collaborative, persuasive approaches for ASP interventions were the norm. Stewards were careful not to criticize or judge inappropriate antibiotic prescribing. Further research should examine whether this persuasive approach undercuts provider appreciation of stewardship as a public health mandate.
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Affiliation(s)
- Tamar F Barlam
- Section of Infectious Diseases, Department of Medicine, School of Medicine, Boston University, Boston, Massachusetts, USA
| | - Ellen Childs
- Department of Health Law, Policy and Management, School of Public Health, Boston University, Boston, Massachusetts, USA
| | - Sarah A Zieminski
- Section of Infectious Diseases, Department of Medicine, School of Medicine, Boston University, Boston, Massachusetts, USA
| | - Tsega M Meshesha
- Department of Health Law, Policy and Management, School of Public Health, Boston University, Boston, Massachusetts, USA
| | - Kathryn E Jones
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
| | - Jorie M Butler
- Department of Internal Medicine, Division of Geriatrics, University of Utah; Geriatric Education and Clinical Center and IDEAS Center of Innovation, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah, USA
| | - Laura J Damschroder
- VA Center for Clinical Management Research, Department of Veterans Affairs, Ann Arbor, Michigan, USA
| | - Matthew Bidwell Goetz
- Veterans Affairs Greater Los Angeles Healthcare System; David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | - Karl Madaras-Kelly
- Boise Veterans Affairs Medical Center; College of Pharmacy, Idaho State University, Meridian, Idaho, USA
| | - Caitlin M Reardon
- VA Center for Clinical Management Research, Department of Veterans Affairs, Ann Arbor, Michigan, USA
| | - Matthew H Samore
- IDEAS Center of Innovation, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah, USA.,Division of Epidemiology, Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Jincheng Shen
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah, USA
| | - Edward Stenehjem
- Office of Patient Experience, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Yue Zhang
- Division of Epidemiology, Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Mari-Lynn Drainoni
- Section of Infectious Diseases, Department of Medicine, School of Medicine, Boston University, Boston, Massachusetts, USA.,Department of Health Law, Policy and Management, School of Public Health, Boston University, Boston, Massachusetts, USA.,Evans Center for Implementation and Improvement Sciences, Department of Medicine, School of Medicine, Boston University, Boston, Massachusetts, USA.,Center for Healthcare Organization and Implementation Research, ENRM VA Hospital, Boston, Massachusetts, USA
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Cho JC, Crotty MP, Kufel WD, Chahine EB, Sofjan AK, Gallagher JC, Estrada SJ. Learning Experiences Within Infectious Diseases Pharmacy Residency Programs in the United States: A Cross-Sectional Survey. Open Forum Infect Dis 2019; 6:ofz387. [PMID: 31660350 PMCID: PMC6790394 DOI: 10.1093/ofid/ofz387] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 09/03/2019] [Indexed: 12/26/2022] Open
Abstract
Background Pharmacists with residency training in infectious diseases (ID) optimize antimicrobial therapy outcomes in patients and support antimicrobial stewardship (AS) programs. Although most ID residencies are accredited and assessed by certain standards, the degree to which these programs are similar is not known. Methods A 19-item, cross-sectional, multicentered, electronic survey was distributed via e-mail to pharmacy residency program directors (RPDs) of all 101 second-year postgraduate (PGY-2) ID residency programs in the United States. Results Survey responses were collected from 71 RPDs (70.3%); 64.8% were associated with an academic medical center and 97.2% focused primarily in adult ID. Rotations in the microbiology laboratory, adult AS, and adult ID consult were required in 98.6% of residency programs. Only 28.2% of responding programs required pediatric AS and pediatric ID consult rotations. Programs at academic medical centers were more likely to offer immunocompromised host ID consult (P = .003), pediatric ID consult (P = .006), and hospital epidemiology (P = .047) rotations but less frequently offered outpatient AS (P = .003), viral hepatitis clinics (P = .001), and travel medicine clinics (P = .007) rotations compared to programs at nonacademic medical centers. Residents were frequently involved in AS committees (97.2%), pharmacokinetic dosing of antimicrobials (83.1%), precepting pharmacy trainees (80.3%), and performing research projects (91.5%). Conclusions The PGY-2 ID pharmacy residency programs demonstrated consistency in required adult ID consult, antimicrobial management activities, committee service, and teaching and research opportunities. Pediatric experiences were less common. The PGY-2 ID residency programs prepare pharmacists to become antimicrobial stewards for adult patients.
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Affiliation(s)
- Jonathan C Cho
- The University of Texas at Tyler Fisch College of Pharmacy, Texas
| | | | - Wesley D Kufel
- Binghamton University School of Pharmacy and Pharmaceutical Sciences, Binghamton, New York
| | - Elias B Chahine
- Palm Beach Atlantic University Lloyd L. Gregory School of Pharmacy, West Palm Beach, Florida
| | | | | | - Sandy J Estrada
- Clinical Affairs, T2 Biosystems, Inc., Lexington, Massachusetts
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Hammond DA, McCreary EK, Rech MA, Smith MN, Yeo QM, Lusardi K, Rhodes NJ, Swanson JM, Bland CM. Perceptions and practices for beta-lactam antibiotic dosing, administration, and monitoring in critically ill patients: Current views and use among critical care and infectious diseases pharmacists. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2019. [DOI: 10.1002/jac5.1084] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Drayton A. Hammond
- Department of Pharmacy; Rush University Medical Center; Chicago Illinois
| | - Erin K. McCreary
- Department of Pharmacy; University of Wisconsin Health; Madison Wisconsin
| | - Megan A. Rech
- Department of Pharmacy; Loyola University Medical Center; Chicago Illinois
| | - Melanie N. Smith
- Department of Pharmacy; Medical University of South Carolina; Charleston South Carolina
| | - Qiu Min Yeo
- Department of Pharmacy; Changi General Hospital; Simei Singapore
| | - Katherine Lusardi
- Department of Pharmacy; University of Arkansas for Medical Sciences; Little Rock Arkansas
| | - Nathaniel J. Rhodes
- Department of Pharmacy Practice; Midwestern University; Downers Grove Illinois
- Department of Pharmacy; Northwestern Memorial Hospital; Chicago Illinois
| | - Joseph M. Swanson
- Department of Pharmacy Practice; University of Tennessee College of Pharmacy; Memphis Tennessee
| | - Christopher M. Bland
- Department of Pharmacy Practice; University of Georgia College of Pharmacy; Savannah Georgia
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