1
|
Schoffelen T, Papan C, Carrara E, Eljaaly K, Paul M, Keuleyan E, Martin Quirós A, Peiffer-Smadja N, Palos C, May L, Pulia M, Beovic B, Batard E, Resman F, Hulscher M, Schouten J. European Society of Clinical Microbiology and Infectious Diseases (ESCMID) guidelines for Antimicrobial Stewardship in Emergency Departments (endorsed by European Association of Hospital Pharmacists). Clin Microbiol Infect 2024:S1198-743X(24)00251-9. [PMID: 39029872 DOI: 10.1016/j.cmi.2024.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 05/24/2024] [Accepted: 05/26/2024] [Indexed: 07/21/2024]
Abstract
SCOPE This ESCMID guideline provides evidence-based recommendations to support a selection of appropriate antibiotic use practices for patients seen in the emergency department (ED) and guidance for their implementation. The topics addressed in this guideline are: 1) Do biomarkers or rapid pathogen tests improve antibiotic prescribing and/or clinical outcomes? 2) Does taking blood cultures in common infectious syndromes improve antibiotic prescribing and/or clinical outcomes? 3) Does watchful waiting without antibacterial therapy or with delayed antibiotic prescribing reduce antibiotic prescribing without worsening clinical outcomes in patients with specific infectious syndromes? 4) Do structured culture follow-up programs in patients discharged from the ED with cultures pending improve antibiotic prescribing? METHODS An expert panel was convened by ESCMID and the guideline chair. The panel selected in consensus the four most relevant AMS topics according to pre-defined relevance criteria. For each main question for the four topics, a systematic review was performed, including randomized controlled trials and observational studies. Both clinical outcomes as well as stewardship process outcomes related to antibiotic use were deemed relevant. The literature searches were conducted between May 2021 and March 2022. In April 2022, the panel members were formally asked to suggest additional studies that were not identified in the initial searches. Data were summarized in a meta-analysis if possible or otherwise summarized narratively. The certainty of the evidence was classified according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. The guideline panel reviewed the evidence per topic critically appraising the evidence and formulated recommendations through a consensus-based process. The strength of the recommendations was classified as strong or weak. To substantiate the implementation process, implementation trials or observational studies describing facilitators/barriers for implementation were identified from the same searches and were summarized narratively. RECOMMENDATIONS The recommendations on the use of biomarkers and rapid pathogen diagnostic tests focus on the initiation of antibiotics in patients admitted through the ED. Their effect on the discontinuation or de-escalation of antibiotics during hospital stay was not reported, neither was their effect on hospital infection prevention and control practices. The recommendations on watchful waiting (i.e., withholding antibiotics with some form of follow-up) focus on specific infectious syndromes for which the primary care literature was also included. The recommendations on blood cultures focus on the indication in three common infectious syndromes in the ED explicitly excluding patients with sepsis or septic shock. Most recommendations are based on very-low- and low-certainty of evidence, leading to weak recommendations or, when no evidence was available, to best practice statements. Implementation of these recommendations needs to be adapted to the specific settings and circumstances of the ED. The scarcity of high-quality studies in the area of antimicrobial stewardship in the ED highlights the need for future research in this field.
Collapse
Affiliation(s)
- Teske Schoffelen
- Radboud Center for Infectious Diseases, Radboud university medical center, Nijmegen, the Netherlands; Department of Internal Medicine, Radboud university medical center, Nijmegen, the Netherlands.
| | - Cihan Papan
- Institute for Hygiene and Public Health, University Hospital Bonn, Bonn, Germany; Centre for Infectious Diseases, Institute of Medical Microbiology and Hygiene, Saarland University, Homburg, Germany
| | - Elena Carrara
- Division of Infectious Diseases, Department of Diagnostic and Public Health, University of Verona, Verona, Italy
| | - Khalid Eljaaly
- Department of Pharmacy Practice, College of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia; King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Mical Paul
- Infectious Diseases, Rambam Health Care Campus, Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Emma Keuleyan
- Department of Clinical Microbiology and Virology, University Hospital Lozenetz, Sofia, Bulgaria; Ministry of Health, Sofia, Bulgaria
| | | | - Nathan Peiffer-Smadja
- Infectious Diseases Department, Bichat-Claude Bernard Hospital, Assistance-Publique Hôpitaux de Paris, Paris, France; Université Paris Cité, INSERM, IAME, F-75018 Paris, France; National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
| | - Carlos Palos
- Hospital da Luz, Infection Control and Antimicrobial Resistance Committee, Lisbon, Portugal
| | - Larissa May
- University of California Davis, Department of Emergency Medicine, Sacramento, CA, USA
| | - Michael Pulia
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Bojana Beovic
- Faculty of Medicine, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Eric Batard
- Emergency Department, CHU Nantes, Nantes, France; Cibles et médicaments des infections et du cancer, IICiMed UR1155, Nantes Université, Nantes, France
| | - Fredrik Resman
- Clinical Infection Medicine, Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Marlies Hulscher
- IQ Health science department, Radboud university medical center, Nijmegen, the Netherlands
| | - Jeroen Schouten
- Radboud Center for Infectious Diseases, Radboud university medical center, Nijmegen, the Netherlands; Department of Intensive Care Medicine, Radboud university medical center, Nijmegen, the Netherlands
| |
Collapse
|
2
|
Sapozhnikov J, Albarillo FS, Pulia MS. Optimizing Antimicrobial Stewardship in the Emergency Department. Emerg Med Clin North Am 2024; 42:443-459. [PMID: 38641398 DOI: 10.1016/j.emc.2024.02.003] [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] [Indexed: 04/21/2024]
Abstract
Antibiotic stewardship is a core component of emergency department (ED) practice and impacts patient safety, clinical outcomes, and public health. The unique characteristics of ED practice, including crowding, time pressure, and diagnostic uncertainty, need to be considered when implementing antibiotic stewardship interventions in this setting. Rapid advances in pathogen detection and host response biomarkers promise to revolutionize the diagnosis of infectious diseases in the ED, but such tests are not yet considered standard of care. Presently, clinical decision support embedded in the electronic health record and pharmacist-led interventions are the most effective ways to improve antibiotic prescribing in the ED.
Collapse
Affiliation(s)
- Julia Sapozhnikov
- Medical Science Liaison, Karius Inc, 975 Island Drive, Redwood City, CA 94065, USA
| | - Fritzie S Albarillo
- Department of Medicine, Infectious Diseases Division, Loyola University Medical Center, Loyola University Medical Center is 2160 South First Avenue, Maywood, IL 60153, USA
| | - Michael S Pulia
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, 800 University Bay Drive, Suite 300, Madison, WI 53705, USA.
| |
Collapse
|
3
|
Arenz L, Porger A, De Michel M, Weber A, Jung J, Horns H, Gscheidle S, Weiglein T, Pircher J, Becker-Lienau J, Horster S, Klein M, Draenert R. Effect and sustainability of a stepwise implemented multidisciplinary antimicrobial stewardship programme in a university hospital emergency department. JAC Antimicrob Resist 2024; 6:dlae026. [PMID: 38410248 PMCID: PMC10895698 DOI: 10.1093/jacamr/dlae026] [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: 11/14/2023] [Accepted: 02/02/2024] [Indexed: 02/28/2024] Open
Abstract
Objectives To explore effectiveness and sustainability of guideline adherence and antibiotic consumption after establishing treatment guidelines and initiating antimicrobial stewardship (AMS) ward rounds in a university hospital emergency department (ED). Methods Data were gathered retrospectively from 2017 to 2021 in the LMU University Hospital in Munich, Germany. Four time periods were compared: P1 (pre-intervention period); P2 (distribution of guideline pocket cards); P3 (reassessment after 3 years); and P4 (refresher of guideline pocket cards and additional daily AMS ward rounds for different medical disciplines). Primary outcome was adherence to guideline pocket cards for community-acquired pneumonia, cystitis, pyelonephritis and COVID-19-associated bacterial pneumonia. Secondary outcomes were reduction in antibiotic consumption and adherence to AMS specialist recommendations. Results The study included 1324 patients. Guideline adherence increased in P2 for each of the infectious diseases entities. After 3 years (P3), guideline adherence decreased again, but was mostly on a higher level than in P1. AMS ward rounds resulted in an additional increase in guideline adherence (P1/P2: 47% versus 58.6%, P = 0.005; P2/P3: 58.6% versus 57.3%, P = 0.750; P3/P4: 57.3% versus 72.5%, P < 0.001). Adherence increased significantly, not only during workdays but also on weekends/nightshifts. Adherence to AMS specialist recommendations was excellent (91.3%). We observed an increase in use of narrow-spectrum antibiotics and a decrease in the application of fluoroquinolones and cephalosporins. Conclusions Establishing treatment guidelines in the ED is effective. However, positive effects can be diminished over time. Daily AMS ward rounds are useful, not only to restore but to further increase guideline adherence significantly.
Collapse
Affiliation(s)
- Lukas Arenz
- Antibiotic Stewardship Programme, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
- Department of Medicine II, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
| | - Annika Porger
- Antibiotic Stewardship Programme, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
| | - Michaela De Michel
- Antibiotic Stewardship Programme, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
| | - Alexandra Weber
- Antibiotic Stewardship Programme, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
- Department of Hospital Pharmacy, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
| | - Jette Jung
- Antibiotic Stewardship Programme, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
- Max-von-Pettenkofer-Institute Munich, LMU Munich, Elisabeth-Winterhalter-Weg 6, 81377 München, Germany
| | - Heidi Horns
- Antibiotic Stewardship Programme, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
| | - Sandra Gscheidle
- Antibiotic Stewardship Programme, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
- Department of Hospital Pharmacy, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
| | - Tobias Weiglein
- Department of Medicine III, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
- Emergency Department, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
| | - Joachim Pircher
- Emergency Department, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
- Department of Medicine I, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
| | - Johanna Becker-Lienau
- Emergency Department, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
- Department of Orthopedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
| | - Sophia Horster
- Emergency Department, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
| | - Matthias Klein
- Emergency Department, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
- Department of Neurology, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
| | - Rika Draenert
- Antibiotic Stewardship Programme, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
| |
Collapse
|
4
|
Tao Y, Wang Y, Zhang Y, Han Y, Feng J, Cheng H, Lin L. A qualitative study of the factors impacting implementation of the national action plan to contain antimicrobial resistance (2016-2020) in medical institutions. BMC Health Serv Res 2024; 24:120. [PMID: 38254103 PMCID: PMC10804545 DOI: 10.1186/s12913-023-10404-y] [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: 05/09/2023] [Accepted: 11/29/2023] [Indexed: 01/24/2024] Open
Abstract
OBJECTIVE Antimicrobial resistance (AMR) has emerged as a serious global public health crisis. In response, 2016, 14 ministries in China, under the leadership of the National Health Commission, collaboratively issued the National Action Plan (NAP) to Contain Antibacterial Resistance (2016-2020). The NAP outlines strategies for medical institutions to adopt stewardship and implement AMR control. The purpose of this study was to comprehend stakeholders' perceptions of the NAP and explore the factors that influence its implementation in medical institutions. METHODS Semi-structured interviews were conducted with practitioners from medical institution in March and April 2021. Interviews were audio-recorded, transcribed and analyzed using thematic analysis via the framework approach. RESULTS Twenty practitioners, representing diverse roles (4 administrators, 7 clinicians, 3 microbiologists, 3 pharmacists, 3 nosocomial infection management personnel) from seven institutions, participated in the study. Substantial efforts have been undertaken to regulate the rational use of antibiotics and enhance the management of hospital infections. Participants demonstrated awareness and concern regarding antimicrobial resistance, with widespread support expressed for the NAP. Among all professions, there were varying opinions on whether they felt restricted in their daily work. The tertiary hospitals have established multidisciplinary cooperation mechanisms. Six main themes were identified as both barriers and facilitators to the implementation of the NAP in the medical institutions: individual factors, leadership, multidisciplinary collaboration, patient factors, training and culture. The capacity for administrative attention is constrained or limited, poor enforcement of guidelines, insufficient specialist staff and the liability pressure on clinicians were perceived barriers. To containing AMR in medical institutions, management of hospital infections, the public's knowledge of antibiotics' usage, routine education and multidisciplinary support would be facilitators. CONCLUSIONS Practitioners from medical institutions were highly supportive for the NAP. Consideration of practitioners' perceived barriers and facilitators might enhance implementation of the NAP to contain antimicrobial resistance.
Collapse
Affiliation(s)
- Yun Tao
- Hospital Management Institute of Wuhan University, Zhongnan Hospital of Wuhan University, Wuhan, 430071, Hubei, China
| | - Ying Wang
- Department of Infectious Diseases, Zhongnan Hospital of Wuhan University, Wuhan, 430071, Hubei, China
| | - Yu Zhang
- Hospital Management Institute of Wuhan University, Zhongnan Hospital of Wuhan University, Wuhan, 430071, Hubei, China
| | - Yong Han
- Hospital Management Institute of Wuhan University, Zhongnan Hospital of Wuhan University, Wuhan, 430071, Hubei, China
| | - Jiajia Feng
- Hospital Management Institute of Wuhan University, Zhongnan Hospital of Wuhan University, Wuhan, 430071, Hubei, China
| | - Hong Cheng
- Department of Pharmacy, Zhongnan Hospital of Wuhan University, Wuhan, 430071, Hubei Province, China.
| | - Likai Lin
- Hospital Management Institute of Wuhan University, Zhongnan Hospital of Wuhan University, Wuhan, 430071, Hubei, China.
| |
Collapse
|
5
|
Bos M, Schouten J, De Bot C, Vermeulen H, Hulscher M. A hidden gem in multidisciplinary antimicrobial stewardship: a systematic review on bedside nurses' activities in daily practice regarding antibiotic use. JAC Antimicrob Resist 2023; 5:dlad123. [PMID: 38021036 PMCID: PMC10667038 DOI: 10.1093/jacamr/dlad123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 11/02/2023] [Indexed: 12/01/2023] Open
Abstract
Background Antimicrobial stewardship (AMS), the set of actions to ensure antibiotics are used appropriately, is increasingly targeted at all those involved in the antimicrobial pathway, including nurses. Several healthcare organizations have issued position statements on how bedside nurses can be involved in AMS. However, it remains unclear how nurses, in reality, contribute to appropriate antibiotic use. Objectives To systematically search the literature to describe the activities bedside nurses perform regarding antibiotic use in daily clinical practice, in relation to the activities proposed by the aforementioned position statements. Methods We searched MEDLINE, Embase, CINAHL and grey literature until March 2021. Studies were included if they described activities regarding antibiotic use performed by bedside nurses. Methodological rigour was assessed by applying the Mixed Method Appraisal Tool. Results A total of 118 studies were included. The majority of the proposed nurses' activities were found in daily practice, categorized into assessment of clinical status, collection of specimens, management of antimicrobial medication, prompting review and educating patient and relatives. Nurses may take the lead in these clinical processes and are communicators in all aspects of the antimicrobial pathway. Patient advocacy appears to be a strong driver of bedside nurses' activities. Conclusions Nurses' activities are already integrated in the day-to-day nursing practice and are grounded in the essence of nursing, being a patient advocate and showing nursing leadership in safeguarding the antimicrobial treatment process. An essential element of the nursing role is communication with other stakeholders in the patient-centred antimicrobial pathway. Educating, engaging and empowering nurses in this already integrated role, could lead to a solid, impactful nursing contribution to AMS.
Collapse
Affiliation(s)
- Maria Bos
- School of Social Work and Health, Avans University of Applied Sciences, ’s Hertogenbosch, The Netherlands
- Scientific Center for Quality of Healthcare (IQ Healthcare), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jeroen Schouten
- Scientific Center for Quality of Healthcare (IQ Healthcare), Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Cindy De Bot
- School of Social Work and Health, Avans University of Applied Sciences, ’s Hertogenbosch, The Netherlands
| | - Hester Vermeulen
- Scientific Center for Quality of Healthcare (IQ Healthcare), Radboud University Medical Center, Nijmegen, The Netherlands
- School of Health, HAN University of Applied Sciences, Nijmegen, The Netherlands
| | - Marlies Hulscher
- Scientific Center for Quality of Healthcare (IQ Healthcare), Radboud University Medical Center, Nijmegen, The Netherlands
| |
Collapse
|
6
|
Padigos J, Reid S, Kirby E, Anstey C, Broom J. Nursing experiences in antimicrobial optimisation in the intensive care unit: A convergent analysis of a national survey. Aust Crit Care 2023; 36:769-781. [PMID: 36404269 DOI: 10.1016/j.aucc.2022.09.005] [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: 06/02/2022] [Revised: 09/08/2022] [Accepted: 09/08/2022] [Indexed: 11/19/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Junel Padigos
- Intensive Care Unit, Sunshine Coast University Hospital, Birtinya, QLD, 4575, Australia; School of Public Health, The University of Queensland, Herston, QLD, 4006, Australia.
| | - Simon Reid
- School of Public Health, The University of Queensland, Herston, QLD, 4006, Australia
| | - Emma Kirby
- Centre for Social Research in Health, University of New South Wales, Sydney NSW, 2052, Australia
| | - Chris Anstey
- School of Medicine and Dentistry, Griffith University, Birtinya, QLD, 4575, Australia; Faculty of Medicine, The University of Queensland, Herston, QLD, 4006, Australia
| | - Jennifer Broom
- Infectious Diseases Research Network, Sunshine Coast University Hospital, Birtinya, QLD, 4575, Australia; Faculty of Medicine, The University of Queensland, Herston, QLD, 4006, Australia
| |
Collapse
|
7
|
Williams DJ, Martin JM, Nian H, Weitkamp AO, Slagle J, Turer RW, Suresh S, Johnson J, Stassun J, Just SL, Reale C, Beebe R, Arnold DH, Antoon JW, Rixe NS, Sartori LF, Freundlich RE, Ampofo K, Pavia AT, Smith JC, Weinger MB, Zhu Y, Grijalva CG. Antibiotic clinical decision support for pneumonia in the ED: A randomized trial. J Hosp Med 2023; 18:491-501. [PMID: 37042682 PMCID: PMC10247532 DOI: 10.1002/jhm.13101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 03/06/2023] [Accepted: 03/23/2023] [Indexed: 04/13/2023]
Abstract
BACKGROUND Electronic health record-based clinical decision support (CDS) is a promising antibiotic stewardship strategy. Few studies have evaluated the effectiveness of antibiotic CDS in the pediatric emergency department (ED). OBJECTIVE To compare the effectiveness of antibiotic CDS vs. usual care for promoting guideline-concordant antibiotic prescribing for pneumonia in the pediatric ED. DESIGN Pragmatic randomized clinical trial. SETTING AND PARTICIPANTS Encounters for children (6 months-18 years) with pneumonia presenting to two tertiary care children s hospital EDs in the United States. INTERVENTION CDS or usual care was randomly assigned during 4-week periods within each site. The CDS intervention provided antibiotic recommendations tailored to each encounter and in accordance with national guidelines. MAIN OUTCOME AND MEASURES The primary outcome was exclusive guideline-concordant antibiotic prescribing within the first 24 h of care. Safety outcomes included time to first antibiotic order, encounter length of stay, delayed intensive care, and 3- and 7-day revisits. RESULTS 1027 encounters were included, encompassing 478 randomized to usual care and 549 to CDS. Exclusive guideline-concordant prescribing did not differ at 24 h (CDS, 51.7% vs. usual care, 53.3%; odds ratio [OR] 0.94 [95% confidence interval [CI]: 0.73, 1.20]). In pre-specified stratified analyses, CDS was associated with guideline-concordant prescribing among encounters discharged from the ED (74.9% vs. 66.0%; OR 1.53 [95% CI: 1.01, 2.33]), but not among hospitalized encounters. Mean time to first antibiotic was shorter in the CDS group (3.0 vs 3.4 h; p = .024). There were no differences in safety outcomes. CONCLUSIONS Effectiveness of ED-based antibiotic CDS was greatest among those discharged from the ED. Longitudinal interventions designed to target both ED and inpatient clinicians and to address common implementation challenges may enhance the effectiveness of CDS as a stewardship tool.
Collapse
Affiliation(s)
- Derek J Williams
- Monroe Carell Jr. Children's Hospital at VUMC, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Judith M Martin
- UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Hui Nian
- Monroe Carell Jr. Children's Hospital at VUMC, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Asli O Weitkamp
- Monroe Carell Jr. Children's Hospital at VUMC, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Jason Slagle
- Monroe Carell Jr. Children's Hospital at VUMC, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | | | - Srinivasan Suresh
- UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jakobi Johnson
- Monroe Carell Jr. Children's Hospital at VUMC, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Justine Stassun
- Monroe Carell Jr. Children's Hospital at VUMC, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Shari L Just
- Monroe Carell Jr. Children's Hospital at VUMC, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Carrie Reale
- Monroe Carell Jr. Children's Hospital at VUMC, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Russ Beebe
- Monroe Carell Jr. Children's Hospital at VUMC, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Donald H Arnold
- Monroe Carell Jr. Children's Hospital at VUMC, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - James W Antoon
- Monroe Carell Jr. Children's Hospital at VUMC, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Nancy S Rixe
- UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Laura F Sartori
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Robert E Freundlich
- Monroe Carell Jr. Children's Hospital at VUMC, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Krow Ampofo
- University of Utah and Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Andrew T Pavia
- University of Utah and Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Joshua C Smith
- Monroe Carell Jr. Children's Hospital at VUMC, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Matthew B Weinger
- Monroe Carell Jr. Children's Hospital at VUMC, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Yuwei Zhu
- Monroe Carell Jr. Children's Hospital at VUMC, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Carlos G Grijalva
- Monroe Carell Jr. Children's Hospital at VUMC, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| |
Collapse
|
8
|
Hashad N, Stewart D, Perumal D, Abdulrazzaq N, Tonna AP. A theoretical exploration of perspectives of key stakeholders on the implementation of antimicrobial stewardship programmes: a qualitative study underpinned by the Consolidated Framework for Implementation Research. J Hosp Infect 2023:S0195-6701(23)00146-9. [PMID: 37211094 DOI: 10.1016/j.jhin.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 05/05/2023] [Accepted: 05/09/2023] [Indexed: 05/23/2023]
Abstract
BACKGROUND While a plethora of studies report antimicrobial stewardship programme (ASP) implementation, these are limited by a lack of theoretical underpinning. This may lead to missing key factors that are likely to influence the successful or unsuccessful implementation. AIM The aim of this study was to explore key stakeholders' perspectives of ASP implementation in United Arab Emirates (UAE) hospitals, with a focus on facilitators and barriers. METHODS The study employed a qualitative approach using semi-structured interviews conducted with ASP stakeholders involved in clinical use of antimicrobials at the individual patient level and including ASP team members and non-members. An interview schedule based on published literature and grounded in the Consolidated Framework for Implementation Research (CFIR) was developed, reviewed, and piloted. Recruitment was via purposive and snowball sampling. Interviews were recorded, transcribed, and thematically analysed by two independent researchers using CFIR as a coding framework. FINDINGS Data saturation was achieved at thirty-one interviews. Multiple CFIR constructs were identified as implementation facilitators or barriers. Facilitators included external policy requirements (both national and international), leadership support, stakeholders' engagement, collaborative culture, effective communication, and forward planning. Barriers included blame culture, complexity of ASP implementation and a shortage of expert personnel. CONCLUSION Numerous facilitators and barriers to ASP implementation from a stakeholders' perspective were identified in this research. The value of early leadership engagement to support provision of required resources, a need for effective planning and establishment of multiple engagement techniques, and valuable communication with healthcare providers are the main recommendations emerging to support improvement in clinical practice.
Collapse
Affiliation(s)
- Nortan Hashad
- Pharmacy, Higher Colleges of Technology, Dubai, United Arab Emirates; School of Pharmacy and Life Sciences, Robert Gordon University, Aberdeen, United Kingdom
| | - Derek Stewart
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar
| | - Dhayaneethie Perumal
- Commission of Academic Accreditation, Ministry of Education, Abu Dhabi, United Arab Emirates
| | - Najiba Abdulrazzaq
- Al Kuwait Hospital, Emirates Health Services, Dubai, United Arab Emirates
| | - Antonella Pia Tonna
- School of Pharmacy and Life Sciences, Robert Gordon University, Aberdeen, United Kingdom.
| |
Collapse
|
9
|
Thursky KA, Hardefeldt LY, Rajkhowa A, Ierano C, Bishop J, Hawes L, Biezen R, Saha SK, Dowson L, Bailey KE, Scarborough R, Little SB, Gotterson F, Hur B, Khanina A, Urbancic K, Crabb HK, Richards S, Sri A, James R, Kong DCM, Marshall C, Mazza D, Peel T, Stuart RL, Manski-Nankervis JA, Friedman ND, Bennett N, Schulz T, Billman-Jacobe H, Buono E, Worth L, Bull A, Richards M, Ayton D, Gilkerson JR, Browning GF, Buising KL. Antimicrobial stewardship in Australia: the role of qualitative research in programme development. JAC Antimicrob Resist 2021; 3:dlab166. [PMID: 34806005 PMCID: PMC8600289 DOI: 10.1093/jacamr/dlab166] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Antimicrobial stewardship (AMS) in Australia is supported by a number of factors, including enabling national policies, sectoral clinical governance frameworks and surveillance programmes, clinician-led educational initiatives and health services research. A One Health research programme undertaken by the National Centre for Antimicrobial Stewardship (NCAS) in Australia has combined antimicrobial prescribing surveillance with qualitative research focused on developing antimicrobial use-related situational analyses and scoping AMS implementation options across healthcare settings, including metropolitan hospitals, regional and rural hospitals, aged care homes, general practice clinics and companion animal and agricultural veterinary practices. Qualitative research involving clinicians across these diverse settings in Australia has contributed to improved understanding of contextual factors that influence antimicrobial prescribing, and barriers and facilitators of AMS implementation. This body of research has been underpinned by a commitment to supplementing 'big data' on antimicrobial prescribing practices, where available, with knowledge of the sociocultural, technical, environmental and other factors that shape prescribing behaviours. NCAS provided a unique opportunity for exchange and cross-pollination across the human and animal health programme domains. It has facilitated synergistic approaches to AMS research and education, and implementation of resources and stewardship activities. The NCAS programme aimed to synergistically combine quantitative and qualitative approaches to AMS research. In this article, we describe the qualitative findings of the first 5 years.
Collapse
Affiliation(s)
- Karin A Thursky
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of Infectious Diseases, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne Health, 300 Grattan Street, Parkville, Victoria 3050, Australia
- Guidance Group, Royal Melbourne Hospital, Melbourne Health, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne and Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, Victoria 3000, Australia
| | - Laura Y Hardefeldt
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Corner Park Drive and Flemington Road, Building 400, Parkville, Victoria 3010, Australia
| | - Arjun Rajkhowa
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of Infectious Diseases, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
| | - Courtney Ierano
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of Infectious Diseases, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
| | - Jaclyn Bishop
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of Infectious Diseases, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Pharmacy Department, Ballarat Health Services, 1 Drummond Street North, Ballarat, Victoria 3353, Australia
| | - Lesley Hawes
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of General Practice, Monash University, 1/270 Ferntree Gully Road, Notting Hill, Victoria 3168, Australia
| | - Ruby Biezen
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of General Practice, Monash University, 1/270 Ferntree Gully Road, Notting Hill, Victoria 3168, Australia
- Department of General Practice, University of Melbourne, 780 Elizabeth Street, Melbourne, Victoria 3010, Australia
| | - Sajal K Saha
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of General Practice, Monash University, 1/270 Ferntree Gully Road, Notting Hill, Victoria 3168, Australia
| | - Leslie Dowson
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, 381 Royal Parade, Parkville, Victoria 3052, Australia
| | - Kirsten E Bailey
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Corner Park Drive and Flemington Road, Building 400, Parkville, Victoria 3010, Australia
| | - Ri Scarborough
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Corner Park Drive and Flemington Road, Building 400, Parkville, Victoria 3010, Australia
| | - Stephen B Little
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Corner Park Drive and Flemington Road, Building 400, Parkville, Victoria 3010, Australia
| | - Fiona Gotterson
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of Infectious Diseases, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
| | - Brian Hur
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Corner Park Drive and Flemington Road, Building 400, Parkville, Victoria 3010, Australia
| | - Anna Khanina
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne and Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, Victoria 3000, Australia
| | - Karen Urbancic
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of Infectious Diseases, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
| | - Helen K Crabb
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Corner Park Drive and Flemington Road, Building 400, Parkville, Victoria 3010, Australia
| | - Suzanna Richards
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Corner Park Drive and Flemington Road, Building 400, Parkville, Victoria 3010, Australia
| | - Anna Sri
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Corner Park Drive and Flemington Road, Building 400, Parkville, Victoria 3010, Australia
| | - Rodney James
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Guidance Group, Royal Melbourne Hospital, Melbourne Health, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
| | - David C M Kong
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Pharmacy Department, Ballarat Health Services, 1 Drummond Street North, Ballarat, Victoria 3353, Australia
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, 381 Royal Parade, Parkville, Victoria 3052, Australia
| | - Caroline Marshall
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of Infectious Diseases, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne Health, 300 Grattan Street, Parkville, Victoria 3050, Australia
| | - Danielle Mazza
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of General Practice, Monash University, 1/270 Ferntree Gully Road, Notting Hill, Victoria 3168, Australia
| | - Trisha Peel
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of Infectious Diseases, The Alfred and Central Clinical School, Burnet Institute, Monash University and Alfred Health, 85 Commercial Road, Monash University, Melbourne, Victoria 3004, Australia
| | - Rhonda L Stuart
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Departments of Infectious Diseases and Infection Control and Epidemiology, Monash Medical Centre, Monash Health, 246 Clayton Road, Clayton, Victoria 3168, Australia
| | - Jo-Anne Manski-Nankervis
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of General Practice, University of Melbourne, 780 Elizabeth Street, Melbourne, Victoria 3010, Australia
| | - N Deborah Friedman
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of Infectious Diseases, University Hospital Geelong, Barwon Health, Bellerine Street, Geelong, Victoria 3220, Australia
| | - Noleen Bennett
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of Infectious Diseases, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Guidance Group, Royal Melbourne Hospital, Melbourne Health, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- VICNISS Coordinating Centre, Melbourne Health, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
| | - Thomas Schulz
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of Infectious Diseases, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne Health, 300 Grattan Street, Parkville, Victoria 3050, Australia
| | - Helen Billman-Jacobe
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Corner Park Drive and Flemington Road, Building 400, Parkville, Victoria 3010, Australia
| | - Evette Buono
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- New South Wales Clinical Excellence Commission, 1 Reserve Road, St Leonards, New South Wales 2065, Australia
| | - Leon Worth
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of Infectious Diseases, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne and Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, Victoria 3000, Australia
| | - Ann Bull
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- VICNISS Coordinating Centre, Melbourne Health, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
| | - Michael Richards
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne Health, 300 Grattan Street, Parkville, Victoria 3050, Australia
- VICNISS Coordinating Centre, Melbourne Health, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
| | - Darshini Ayton
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, Victoria 3004, Australia
| | - James R Gilkerson
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Corner Park Drive and Flemington Road, Building 400, Parkville, Victoria 3010, Australia
| | - Glenn F Browning
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Corner Park Drive and Flemington Road, Building 400, Parkville, Victoria 3010, Australia
| | - Kirsty L Buising
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of Infectious Diseases, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne Health, 300 Grattan Street, Parkville, Victoria 3050, Australia
- Guidance Group, Royal Melbourne Hospital, Melbourne Health, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Peter Doherty Institute of Infection and Immunity, 792 Elizabeth Street, Melbourne Victoria, 3000, Australia
| |
Collapse
|
10
|
Livorsi DJ, Nair R, Dysangco A, Aylward A, Alexander B, Smith MW, Kouba S, Perencevich EN. Using Audit and Feedback to Improve Antimicrobial Prescribing in Emergency Departments: A Multicenter Quasi-Experimental Study in the Veterans Health Administration. Open Forum Infect Dis 2021; 8:ofab186. [PMID: 34113685 DOI: 10.1093/ofid/ofab186] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 04/11/2021] [Indexed: 11/15/2022] Open
Abstract
Background In this pilot trial, we evaluated whether audit-and-feedback was a feasible strategy to improve antimicrobial prescribing in emergency departments (EDs). Methods We evaluated an audit-and-feedback intervention using a quasi-experimental interrupted time-series design at 2 intervention and 2 matched-control EDs; there was a 12-month baseline, 1-month implementation, and 11-month intervention period. At intervention sites, clinicians received (1) a single, one-on-one education about antimicrobial prescribing for common infections and (2) individualized feedback on total and condition-specific (uncomplicated acute respiratory infection [ARI]) antimicrobial use with peer-to-peer comparisons at baseline and every quarter. The primary outcome was the total antimicrobial-prescribing rate for all visits and was assessed using generalized linear models. In an exploratory analysis, we measured antimicrobial use for uncomplicated ARI visits and manually reviewed charts to assess guideline-concordant management for 6 common infections. Results In the baseline and intervention periods, intervention sites had 28 016 and 23 164 visits compared to 33 077 and 28 835 at control sites. We enrolled 27 of 31 (87.1%) eligible clinicians; they acknowledged receipt of 33.3% of feedback e-mails. Intervention sites compared with control sites had no absolute reduction in their total antimicrobial rate (incidence rate ratio = 0.99; 95% confidence interval, 0.98-1.01). At intervention sites, antimicrobial use for uncomplicated ARIs decreased (68.6% to 42.4%; P < .01) and guideline-concordant management improved (52.1% to 72.5%; P < .01); these improvements were not seen at control sites. Conclusions At intervention sites, total antimicrobial use did not decrease, but an exploratory analysis showed reduced antimicrobial prescribing for viral ARIs. Future studies should identify additional targets for condition-specific feedback while exploring ways to make electronic feedback more acceptable.
Collapse
Affiliation(s)
- Daniel J Livorsi
- Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Rajeshwari Nair
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Andrew Dysangco
- Indiana University School of Medicine and the Richard L. Roudebush VA Medical Center, Indianapolis, Indiana, USA
| | - Andrea Aylward
- Sioux Falls VA Health Care System, Sioux Falls, South Dakota, USA
| | - Bruce Alexander
- Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA
| | - Matthew W Smith
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Sammantha Kouba
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Eli N Perencevich
- Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| |
Collapse
|
11
|
Novak F, Hørlück JT, Redder JD, Denton PW, Storgaard M. Poor compliance with an antibiotic directive-A call for intensified monitoring. Int J Infect Dis 2021; 104:474-478. [PMID: 33465487 DOI: 10.1016/j.ijid.2021.01.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 01/11/2021] [Accepted: 01/13/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND In April 2017, the Central Denmark Region Antibiotic Stewardship Committee issued a directive to reduce the general use of piperacillin-tazobactam and prescribe narrow-spectrum antibiotics for mild and moderate pneumonia. The directive was distributed to all regional hospital clinicians. METHODS Electronic medical records were used to obtain de-identified details of all antibiotics administered (together with diagnosis codes) to all in-hospital patients (pre-directive and post-directive) in the nine regional hospitals. Average moving range statistical process control charts were used to analyze pre-directive and post-directive variation in antibiotic usage patterns. RESULTS Upon the distribution of the directive, a period of decline of the overall usage of piperacillin-tazobactam ensued. Rather than benzylpenicillin, as recommended for pneumonia, the initial decline in piperacillin/tazobactam usage was accompanied by increased use of cefuroxime. CONCLUSIONS A steward-directed reduction in piperacillin-tazobactam usage was accompanied by less desirable usage of a broad-spectrum alternative. Future antibiotic stewardship initiatives will hopefully benefit from close monitoring and timely feedback to clinicians. A dialogue with clinicians based on near real-time data is predicted to improve antibiotic stewardship actions.
Collapse
Affiliation(s)
- Frederik Novak
- Department of Infectious Diseases, Aarhus University Hospital, Skejby, Aarhus, Denmark
| | | | - Jacob D Redder
- Business Intelligence Office, Department of Information Technology, Central Denmark Region, Aarhus, Denmark
| | - Paul W Denton
- Department of Infectious Diseases, Aarhus University Hospital, Skejby, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Universityof Nebraska at Omaha, Department of Biology, Omaha, Nebraska, USA
| | - Merete Storgaard
- Department of Infectious Diseases, Aarhus University Hospital, Skejby, Aarhus, Denmark.
| |
Collapse
|
12
|
Paul M, Pulia M, Pulcini C. Antibiotic stewardship in the emergency department: not to be overlooked. Clin Microbiol Infect 2020; 27:172-174. [PMID: 33253938 DOI: 10.1016/j.cmi.2020.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 11/18/2020] [Accepted: 11/19/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Mical Paul
- Rambam Health Care Campus, The Ruth and Bruce Rappaport Faculty of Medicine Technion, Israel Institute of Technology, Haifa, Israel.
| | - Michael Pulia
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, WI, USA
| | - Céline Pulcini
- Université de Lorraine, APEMAC, équipe MICS, Nancy, France; Université de Lorraine, CHRU-Nancy, Infectious Diseases Department, Nancy, France
| |
Collapse
|
13
|
Stefan MS, Spitzer KA, Zulfiqar S, Heineman BD, Hogan TP, Westafer LM, Pulia MS, Pinto-Plata VM, Lindenauer PK. Uncertainty as a critical determinant of antibiotic prescribing in patients with an asthma exacerbation: a qualitative study. J Asthma 2020; 59:352-361. [PMID: 33158364 DOI: 10.1080/02770903.2020.1847929] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To identify factors that influence providers' decisions to prescribe antibiotics in patients presenting to the hospital with an asthma exacerbation. METHODS We performed semi-structured interviews with a purposive sample of providers including sixteen hospitalists, emergency room providers, or pulmonologists, and one focus group with internal medicine residents recruited from one large, urban, teaching hospital and one small, rural, community hospital. Questions were informed by the Theoretical Domains Framework to determine factors that may influence behaviors. Directed content analysis was used to code and analyze transcripts of the interviews. RESULTS Uncertainty regarding the diagnostic (asthma vs. COPD) and the cause of exacerbation (bacterial vs. viral infection) emerged as the main driver for prescribing behavior. Provider response to uncertainty included: "watchful waiting" or immediate antibiotic prescribing. The following factors played important roles in providers' prescribing decision: 1) awareness/agreement with existing guidelines 2) confidence in their ability to apply the guidelines in challenging cases; 3) perceived risk of patient deterioration without antibiotics; 4) fear of litigation; 5) habit and clinical inertia 6) prescribing within the group 7) lack of information of antibiotic prescribing rates and 8) lack of time and/or resources. CONCLUSIONS We identified diagnostic uncertainty as the primary determinant of antibiotic prescribing in asthma exacerbations and developed a conceptual model to explain provider responses and factors that influenced their responses. These results enhance our understanding of the factors that can contribute to low-value and wasteful practices like superfluous antibiotic prescribing and will support the development of interventions to de-implement such practices.
Collapse
Affiliation(s)
- Mihaela S Stefan
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School - Baystate, Springfield, MA, USA.,Department of Medicine, University of Massachusetts Medical School - Baystate, Springfield, MA, USA
| | - Kerry A Spitzer
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School - Baystate, Springfield, MA, USA
| | - Sehar Zulfiqar
- Department of Medicine, University of Massachusetts Medical School - Baystate, Springfield, MA, USA
| | - Brent D Heineman
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School - Baystate, Springfield, MA, USA
| | - Timothy P Hogan
- Center for Healthcare Organization and Implementation Research (CHOIR), Edith Nourse Rogers Memorial Veterans Hospital, US Department of Veterans Affairs, Bedford, MA, USA.,Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Lauren M Westafer
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School - Baystate, Springfield, MA, USA.,Department of Emergency Medicine, University of Massachusetts Medical School - Baystate, Springfield, MA, USA
| | - Michael S Pulia
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin Madison, School of Medicine and Public Health, Madison, WI, USA
| | - Victor M Pinto-Plata
- Department of Medicine, University of Massachusetts Medical School - Baystate, Springfield, MA, USA.,Divsion of Pulmonary and Critical Care Medicine, University of Massachusetts Medical School - Baystate, Springfield, MA, USA
| | - Peter K Lindenauer
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School - Baystate, Springfield, MA, USA.,Department of Medicine, University of Massachusetts Medical School - Baystate, Springfield, MA, USA.,Department of Quantitative and Population Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| |
Collapse
|
14
|
May L, Martín Quirós A, Ten Oever J, Hoogerwerf J, Schoffelen T, Schouten J. Antimicrobial stewardship in the emergency department: characteristics and evidence for effectiveness of interventions. Clin Microbiol Infect 2020; 27:204-209. [PMID: 33144202 DOI: 10.1016/j.cmi.2020.10.028] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 10/21/2020] [Accepted: 10/24/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Emergency departments (EDs) are the entrance gates for patients presenting with infectious diseases into the hospital, yet most antimicrobial stewardship programmes are primarily focused on inpatient management. With equally high rates of inappropriate antibiotic use, the ED is a frequently overlooked yet important unit for targeted antimicrobial stewardship (AMS) interventions. OBJECTIVES We aimed to (a) describe the specific aspects of antimicrobial stewardship in the ED and (b) summarize the findings from improvement studies that have investigated the effectiveness of antimicrobial stewardship interventions in the ED setting. SOURCES (a) a PubMed search for 'antimicrobial stewardship' and 'emergency department', and (b) published reviews on effectiveness combined with publications from the first source. CONTENT (a) An in depth analysis of selected publications provided four key antimicrobial use processes typically performed by front-line healthcare professionals in the ED: making a (tentative) clinical diagnosis, starting empirical therapy based on that diagnosis, performing microbiological tests before starting that therapy and following up patients who are discharged from the ED. (b) Further, we discuss the literature on improvement strategies in the ED focusing on guidelines and clinical pathways and multifaceted improvement strategies. We also summarize the evidence of microbiologic culture review. IMPLICATIONS Based on our review of the literature, we describe four essential elements of antimicrobial use in the ED. Studying the various interventions targeting these care processes, we have found them to be of a variable degree of success. Nonetheless, while there is a paucity of AS studies specifically targeting the ED, there is a growing body of evidence that AS programmes in the ED are effective with modifications to the ED setting. We present key questions for future research.
Collapse
Affiliation(s)
- Larissa May
- Department of Emergency Medicine, University of California Davis, Sacramento, CA, USA
| | | | - Jaap Ten Oever
- Department of Internal Medicine, Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jacobien Hoogerwerf
- Department of Internal Medicine, Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Teske Schoffelen
- Department of Internal Medicine, Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jeroen Schouten
- Scientific Center for Quality of Healthcare (IQ Healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands; Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, the Netherlands.
| |
Collapse
|
15
|
Gotterson F, Buising K, Manias E. Nurse role and contribution to antimicrobial stewardship: An integrative review. Int J Nurs Stud 2020; 117:103787. [PMID: 33647845 DOI: 10.1016/j.ijnurstu.2020.103787] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 08/05/2020] [Accepted: 09/28/2020] [Indexed: 01/22/2023]
Abstract
AIM To examine existing published literature regarding nurses and antimicrobial stewardship, and their potential role and contribution, to identify what is known, to evaluate methodologies used in published research, and to review and integrate findings to inform practice and future priorities for research. DESIGN Integrative review. METHODOLOGY The approach to this review was informed by Whittemore and Knafl's integrative review methodology. Electronic databases were searched for papers published since the start of the database to November 2019, with abstracts available, related to humans and published in English. Papers were included regardless of practice setting (acute, aged, and primary care) and if they were research based, included nurses as participants and reported specifically on results from nurses or that had implications for nursing practice. Excluded were conference abstracts, and papers focussed solely on nurse prescriber, nurse practitioner, or nurse manager roles. RESULTS Fifty-two papers were included in the review. Identified themes were: i) nursing knowledge, learning needs and education; ii) nurse perceptions of the nursing role and motivations for involvement; iii) nursing brokerage and influence on information flow to and from patients; iv) nursing workflow, workload and workarounds; and v) nurse leadership. Methodological quality of the included papers varied, limiting transferability and applicability of findings for some of the included studies. CONCLUSION Formal inclusion of nurses in antimicrobial stewardship activities has been associated with improved nurse knowledge, nurse confidence, and in some cases improved clinical outcomes for patients. The review reinforces nursing values as a motivator of nursing actions, and reveals the complex yet significant influence of nurses on antimicrobial prescribing. Potential opportunities to enhance nurses' participation and contribution to antimicrobial stewardship include; formal acknowledgement of the nurse role, educating nurses so that they are aware of how they can contribute, collaborating with nurses in planning and implementing local stewardship activities, and ensuring nurse leaders are involved. However, evidence on this topic remains limited. Research is needed to facilitate greater understanding about the nature, scope and influence of the nurse role in antimicrobial stewardship, how nurses enact and carry out their role, and nurses' support needs. Tweetable abstract: Integrative review explores #nurse role in #antimicrobialstewardship. Nurse contribution, influence significant, but not well understood.
Collapse
Affiliation(s)
- Fiona Gotterson
- National Centre for Antimicrobial Stewardship, The Peter Doherty Institute for Infections and Immunity, 792 Elizabeth St, Melbourne, VIC 3000, Australia; Department of Medicine, Building 181, University of Melbourne, Grattan St, Melbourne, VIC 3010, Australia.
| | - Kirsty Buising
- National Centre for Antimicrobial Stewardship, The Peter Doherty Institute for Infections and Immunity, 792 Elizabeth St, Melbourne, VIC 3000, Australia; Department of Medicine, Building 181, University of Melbourne, Grattan St, Melbourne, VIC 3010, Australia; Victorian Infectious Diseases Service, The Peter Doherty Institute for Infections and Immunity, 792 Elizabeth St, Melbourne, VIC 3000, Australia
| | - Elizabeth Manias
- Deakin University, School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Institute for Health Transformation, 221 Burwood Highway, Burwood, VIC 3125, Australia; The Royal Melbourne Hospital, Department of Medicine, Royal Parade, Parkville, VIC 3052, Australia
| |
Collapse
|
16
|
Benkő R, Gajdács M, Matuz M, Bodó G, Lázár A, Hajdú E, Papfalvi E, Hannauer P, Erdélyi P, Pető Z. Prevalence and Antibiotic Resistance of ESKAPE Pathogens Isolated in the Emergency Department of a Tertiary Care Teaching Hospital in Hungary: A 5-Year Retrospective Survey. Antibiotics (Basel) 2020; 9:antibiotics9090624. [PMID: 32961770 PMCID: PMC7560131 DOI: 10.3390/antibiotics9090624] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 09/13/2020] [Accepted: 09/17/2020] [Indexed: 12/20/2022] Open
Abstract
Antibiotic treatments initiated on Emergency Departments (ED) are empirical. Therefore, knowledge of local susceptibility patterns is important. Despite this, data on expected pathogens and their resistance profile are scarce from EDs internationally. The study aim was to assess the epidemiology and resistance patterns of bacterial isolates from a tertiary-care ED over 5 years, focusing on ESKAPE bacteria (including the Enterobacterales group). After removal of duplicates, n = 6887 individual bacterial isolates were recovered, out of which n = 4974 (72.22%) were ESKAPE isolates. E. coli was the most frequent isolate (2193, 44.1%), followed by the Klebsiella genus (664; 13.4%). The third most frequent isolate was S. aureus (561, 11.3%). In total, multi-drug resistance (MDR) was present in 23.8% and was most prevalent in A. baumanii (65.5%), P. mirabilis (42.7%), and K. pneumoniae (32.6%). MRSA was isolated in 19.6%, while ESBL-producing Enterobacterales in 17.7%, and these were associated with remarkably higher resistance to other antibacterials as well. Difficult-to-treat resistance (DTR) was detected in 0.5%. The frequent isolation of some ESKAPE bacteria and the detected considerable acquired resistance among ED patients raise concern. The revealed data identified problematic pathogens and will guide us to set up the optimal empiric antibiotic protocol for clinicians.
Collapse
Affiliation(s)
- Ria Benkő
- Department of Clinical Pharmacy, Faculty of Pharmacy, University of Szeged, 6725 Szeged, Hungary;
- Central Pharmacy Department, University of Szeged, Albert Szent-Györgyi Health Center, 6725 Szeged, Hungary;
- Department of Emergency Medicine, University of Szeged, Albert Szent-Györgyi Health Center, 6725 Szeged, Hungary; (P.H.); (P.E.); (Z.P.)
- Correspondence: ; Tel.: +36-62-342572
| | - Márió Gajdács
- Department of Pharmacodynamics and Biopharmacy, Faculty of Pharmacy, University of Szeged, 6720 Szeged, Hungary;
| | - Mária Matuz
- Department of Clinical Pharmacy, Faculty of Pharmacy, University of Szeged, 6725 Szeged, Hungary;
- Central Pharmacy Department, University of Szeged, Albert Szent-Györgyi Health Center, 6725 Szeged, Hungary;
| | - Gabriella Bodó
- Central Pharmacy Department, University of Szeged, Albert Szent-Györgyi Health Center, 6725 Szeged, Hungary;
| | - Andrea Lázár
- Institute of Clinical Microbiology, Faculty of Medicine, University of Szeged, 6725 Szeged, Hungary;
| | - Edit Hajdú
- Infectious Disease Ward, 1st Department of Internal Medicine, University of Szeged, Albert Szent-Györgyi Medical Center, 6725 Szeged, Hungary; (E.H.); (E.P.)
| | - Erika Papfalvi
- Infectious Disease Ward, 1st Department of Internal Medicine, University of Szeged, Albert Szent-Györgyi Medical Center, 6725 Szeged, Hungary; (E.H.); (E.P.)
| | - Peter Hannauer
- Department of Emergency Medicine, University of Szeged, Albert Szent-Györgyi Health Center, 6725 Szeged, Hungary; (P.H.); (P.E.); (Z.P.)
| | - Péter Erdélyi
- Department of Emergency Medicine, University of Szeged, Albert Szent-Györgyi Health Center, 6725 Szeged, Hungary; (P.H.); (P.E.); (Z.P.)
| | - Zoltán Pető
- Department of Emergency Medicine, University of Szeged, Albert Szent-Györgyi Health Center, 6725 Szeged, Hungary; (P.H.); (P.E.); (Z.P.)
| |
Collapse
|