A survey of medical staff attitudes to an antibiotic approval and stewardship programme

Exploring unintended consequences of adult antimicrobial stewardship programs: An Emerging Infections Network survey

We performed a survey of adult infectious diseases (ID) physicians to explore unintended consequences of antimicrobial stewardship programs (ASP). ID physicians worried about disagreement with colleagues, provider autonomy, and remote recommendations. Non-ASP ID physicians expressed more concern regarding ASPs focus on costs, provider efficiency, and unintended consequences of ASP guidance.

Indonesian healthcare providers' perceptions and attitude on antimicrobial resistance, prescription and stewardship programs

Background: A successful antimicrobial stewardship program (ASP) is sustained through improving antimicrobial prescribing by changing prescribing behavior. This requires a better understanding of hospital stakeholders' views regarding antimicrobial resistance (AMR), antimicrobial use and participation in ASP activities. Objectives: Identify perceptions and attitudes among physicians and pharmacists in a public hospital toward AMR, prescription and ASP. Methods: A questionnaire consisting of 45 items was distributed to physicians and pharmacists in a 320-bed public hospital. All responses were formatted into the Likert scale. Results: A total of 78 respondents (73% response rate) completed the questionnaire. The majority of the respondents perceived AMR within hospital as less of a severe problem, and factors outside hospital were considered to be greater contributors to AMR. In addition, interprofessional conflict was identified as a serious concern in relation to implementing ASP. Conclusion: This finding indicates the need to address existing perceptions and attitudes toward ASP activities that may hamper its successful implementation in Indonesia.

Exploring Physicians' Views, Perceptions and Experiences about Broad-Spectrum Antimicrobial Prescribing in a Tertiary Care Hospital Riyadh, Saudi Arabia: A Qualitative Approach

Antimicrobial resistance (AMR) is a global public health threat associated with increased mortality, morbidity and costs. Inappropriate antimicrobial prescribing, particularly of broad-spectrums antimicrobials (BSAs), is considered a major factor behind growing AMR. The aim of this study was to explore physician perception and views about BSAs and factors that impact upon their BSAs prescribing decisions. Qualitative semistructured telephone interviews over an eleven-week period were conducted with physicians in a single tertiary care hospital in Riyadh, Saudi Arabia. Purposeful and snowball sampling techniques were adopted as sampling strategy. All interviews were audio recorded, transcribed verbatim, uploaded to NVivo^® software and analysed following thematic analysis approach. Four major themes emerged: views on BSAs, factors influencing BSA prescribing and antimicrobial stewardship: practices and barriers and recommendations to improve appropriate BSA prescribing. Recommendations for the future include improving clinical knowledge, feedback on prescribing, multidisciplinary team decision-making and local guideline implementation. Identification of views and determinants of BSA prescribing can guide the design of a multifaceted intervention to support physicians and policymakers to improve antimicrobial prescribing practices.

Physicians' attitudes on the implementation of an antimicrobial stewardship program in Lebanese hospitals

BACKGROUND

Misuse of antibiotics and antimicrobial resistance are global concerns. Antibiotic stewardship programs (ASP) are advocated to reduce pathogens resistance by ensuring appropriate antimicrobial use. Several factors affect the implementation of ASPs in hospitals. The size and types of care provided, as well as the complexity of antibiotic prescription, are all issues that are considered in designing an effective hospital-based program.

OBJECTIVES

To examine physicians' attitude on implementation of an antimicrobial stewardship program in Lebanese hospitals.

METHODS

A descriptive cross-sectional survey was carried out using an online questionnaire. Survey items assessed ASP implementations, physicians' attitudes, usefulness of the tools, and barriers of implementation. The questionnaire was based on the Center for Disease Control core-elements.

RESULTS

158 physicians completed the survey with a response rate of 4%. Our results showed that the majority (66%) of physicians were familiar with the ASP concept. Most respondents reported a lack of regular educational programs (41%), as well as a lack of support from the medical staff (76%). This study demonstrated positive attitudes and support for ASP implementation. However, ASPs were reported as affecting physicians' autonomy by 34 % of the participants. Antibiotic rounds and prospective audit and feedback were rated as most useful interaction methods with the ASPs. A minimal support of the Ministry Of Public Health, as well as the absence of regulation and of national guidelines, were reported as barriers to ASPs. The shortage of Infectious Disease physicians was seen as a barrier by half of the respondents.

CONCLUSIONS

Physicians are supportive of ASP, with preference for interventions that provide information and education rather than restrictive ones. Additional research is needed on a larger sample of physicians.

Physicians' Perspective on Prescribing Patterns and Knowledge on Antimicrobial Use and Resistance in Penang, Malaysia: A Qualitative Study

Background: Unnecessary antimicrobial use is an emerging problem throughout the world. To design future interventions to ensure rational antimicrobial use and decrease the risk of antimicrobial resistance, physician's knowledge and prescribing practices of antimicrobials should be assessed. Therefore, the main objective of this study is to investigate the physician's knowledge along with their prescribing patterns of antimicrobials in their health care system.

Methods: The present qualitative study was conducted in a tertiary care public hospital located at Penang island, situated in Northwest of Malaysia. A total of 12 semi-structured, face to face interviews were conducted with purposive sampling technique. Physicians recruited had different specialties. All interviews were audio recorded, then transcribed into English language and analyze by thematic content analysis.

Results: Four major themes were identified: (1) prescribing patterns of physicians regarding antimicrobials; (2) physician's knowledge about antimicrobials; (3) antimicrobial resistance; (4) satisfaction with management of infections. Physicians believed in regular educational activities and updates about the latest antimicrobial guidelines may change the prescribing behavior of physicians to optimize the use of antimicrobials. This may lead to decrease in burden of antimicrobial resistance in their health care system. Physicians emphasized that stricter rules and regular monitoring of antimicrobial use should be implemented to overcome the main challenges of antimicrobial resistance.

Conclusion: Different factors were identified to assist optimized use of antimicrobials and decrease the risk of antimicrobial resistance. The present study helps to design targeted future interventions to ensure rational antimicrobial use and decrease the impact of antimicrobial resistance in Malaysia.

The viral prescription pad - a mixed methods study to determine the need for and utility of an educational tool for antimicrobial stewardship in primary health care

Background

In order to combat rising rates of antimicrobial resistant infections, it is vital that antimicrobial stewardship become embedded in primary health care (PHC). Despite the high use of antimicrobials in PHC settings, there is a lack of data regarding the integration of antimicrobial stewardship programs (ASP) in non-hospital settings. Our research aimed to determine which antimicrobial stewardship interventions are optimal to introduce into PHC clinics beginning to engage with an ASP, as well as how to optimize those interventions. This work became focused specifically around management of viral upper respiratory tract infections (URTIs), as these infections are one of the main sources of inappropriate antibiotic use.

Methods

This mixed methods study of sequential explanatory design was developed through three research projects over 3 years in Regina, Saskatchewan, Canada. First, a survey of PHC providers was performed to determine their perceived needs from a PHC-based ASP. From this work, a “viral prescription pad” was developed to provide a tool to help PHC providers engage in patient education regarding appropriate antimicrobial use, specifically for URTIs. Next, interviews were performed with family physicians to discuss their perceived utility of this tool. Finally, we performed a public survey to determine preferences for the medium by which information is received regarding symptom management for viral URTIs.

Results

The majority of PHC providers responding to the initial survey indicated they were improperly equipped with tools to aid in promoting conversations with patients and providing education about the appropriate use of antimicrobials. Following dissemination of the viral prescription pad and semi-structured interviews with family physicians, the viral prescription pad was deemed to be a useful educational tool. However, about half of the physicians interviewed indicated they did not actually provide a viral prescription to patients when providing advice on symptom management for viral URTIs. When asked about their preferences, 76% of respondents to the public survey indicated they would prefer to receive written or a combination of verbal and written information in this circumstance.

Conclusions

PHC providers indicated a need for educational tools to promote conversations with patients and provide education about the appropriate use of antimicrobials. Viral prescription pads were regarded by family physicians and patients as useful tools in facilitating discussion on the appropriate use of antimicrobials. PHC providers should exercise caution in opting out of providing written forms of information, as many respondents to the general public survey indicated their preference in receiving both verbal and written information.

Attitude of clinicians towards hospital-based antimicrobial stewardship programs: a multicenter cross-sectional study from Punjab, Pakistan

Background: Antimicrobial resistance (AMR) is a major threat to global health and antimicrobial stewardship programs (ASPs) are useful to limit the momentum of AMR. This study was intended to determine the attitudes of clinicians about AMR, ASP strategies, and their readiness to participate in ASPs. Methods: A cross-sectional survey was carried out among clinicians working in teaching hospitals of Punjab between August and November 2018. A multistage sampling method was used. Descriptive statistics and Kruskal-Wallis tests were employed for data analysis. Results: A response rate of 77.9% (670 ⁄ 859) was achieved. Most of the physicians (n = 302, 71.7%) compared to surgeons (n = 134, 70.9%) and anesthetists (n = 25, 41.7%) considered AMR as a serious health problem in Pakistani hospitals (p < 0.001). Clinicians were agreed that hospital audit and feedback (n = 434, 64.8%), restriction of certain antibiotics (n = 424, 63.3%), readily accessible microbiological data (n = 453, 67.6%), and regular educational sessions (n = 496, 74.0%) are imperative approaches to implement ASPs. Median ASP and AMR scores were significantly associated with age, experience, and types of clinicians (p < 0.05). Conclusions: Despite poor previous knowledge of ASPs, all clinicians showed a positive attitude towards hospital ASPs. Several approaches suggested by clinicians will be helpful to implement hospital ASPs in Pakistan.

Antimicrobial prescribing and determinants of antimicrobial resistance: a qualitative study among physicians in Pakistan

Background Understanding physicians' perception about antimicrobial use and resistance is essential to ensure that the objectives of the Pakistan national action plan on antimicrobial resistance are met. Little is currently known about physicians' perceptions in Pakistan. Objective Assess physicians' perception surrounding antibiotic use and resistance, factors influencing antibiotic prescribing and potential interventions to improve future antibiotic prescribing. Settings The study was conducted in Lahore, the capital of the province of Punjab, which is the second largest and most populous city of Pakistan. Method Qualitative study was conducted with a semi-structured interview guide involving in-depth face-to-face interviews with purposively selected physicians. Audiorecorded interviews were transcribed verbatim and transcripts analyzed by thematic content analysis. Main outcome measures Themes surrounding the perspectives of physicians on issues of antimicrobial use and resistance. Results Five major themes emerged: (1) knowledge and perception of physicians about antimicrobials, (2) antimicrobial prescribing behaviors of physicians, (3) factors influencing prescribing, (4) determinants of antimicrobial resistance, (5) and potential interventions to reduce antimicrobial resistance. The main challenges and issues associated with antibiotic prescribing were the improvement of knowledge, implementation of hygienic measures, access to and clarity of treatment recommendations and minimizing external factors influencing prescribing including pharmaceutical company activities. Suggestions for the future included stricter regulations for prescribing, improved diagnosis, availability of local guidelines and monitoring of prescribing and resistance patterns. Conclusion Identification of concerns regarding inappropriate antimicrobial prescribing will enable specific initiatives and approaches to improve future antimicrobial use and reduce antimicrobial resistance in Pakistan.

Perspective of Pakistani Physicians towards Hospital Antimicrobial Stewardship Programs: A Multisite Exploratory Qualitative Study

Background: Antimicrobial resistance (AMR) is a global threat and the antimicrobial stewardship program (ASP) is a globally used tool to combat AMR. There is little information on the views among Pakistani physicians regarding AMR and the benefits of hospital antimicrobial stewardship implementation. This study was designed to explore the physicians’ views about ASP. Methods: Qualitative face-to-face and telephonic interviews were conducted by using purposive sampling method with 22 physicians working in seven tertiary care public hospitals of Punjab, Pakistan. All interviews were audio recorded and transcribed verbatim. Qualitative software was used, and a thematic analysis was conducted. Results: Three broad themes were identified: (1) the growing concern of antimicrobial resistance in Pakistan, (2) the role(s) of healthcare professionals in antibiotic prescribing, and (3) managing antibiotic resistance in hospitals. Inadequate resources, poor healthcare facilities, and insufficiently trained medical staff were the major hurdles in ASP implementation in Pakistan. Conclusions: Our study found a poor familiarity of hospital ASP among physicians working in public sector tertiary care teaching hospitals, and a number of distinct themes emerged during this study that could be helpful in establishing the concept of hospital ASP in Pakistan. Overall, physicians showed a positive attitude towards the enforcement of ASP in all healthcare settings, including teaching hospitals.

Threatened efficiency not autonomy: Prescriber perceptions of an established pediatric antimicrobial stewardship program

BACKGROUND

Implementing antimicrobial stewardship programs (ASPs) can be challenging due to prescriber resistance. Although barriers to implementing new ASPs have been identified, little is known about how prescribers perceive established programs. This information is critical to promoting the sustainability of ASPs.

OBJECTIVE

To identify how prescribers perceive an established pediatric inpatient ASP that primarily utilizes prior authorization.

METHODS

We conducted a cross-sectional survey administered from February through June 2017 in a large children's hospital. The survey contained closed- and open-ended questions. Descriptive statistics and thematic content analysis approaches were used to analyze responses.

RESULTS

Of 394 prescribers invited, 160 (41%) responded. Prescribers had an overall favorable impression of the ASP, believing that it improves the quality of care (92.4% agree) and takes their judgment seriously (73.8%). The most common criticism of the ASP was that it threatened efficiency (26.0% agreed). In addition, 68.7% of respondents reported occasionally engaging in workarounds. Analysis of 133 free-text responses revealed that prescribers perceived that interacting with the ASP involved too many phone calls, caused communication breakdowns with the dispensing pharmacy, and led to gaps between approval and dispensing of antibiotics. Reasons given for workarounds included not wanting to change therapy that appears to be working, consultant disagreement with ASP recommendations, and the desire to do everything possible for patients.

CONCLUSIONS

Prescribers had a generally favorable opinion of an established ASP but found aspects to be inefficient. They reported engaging in workarounds occasionally for social and emotional reasons. Established ASPs should elicit feedback from frontline prescribers to optimize program impact.

Towards a global definition of responsible antibiotic use: results of an international multidisciplinary consensus procedure

Background

Conducted as part of the Driving Reinvestment in Research and Development and Responsible Antibiotic Use (DRIVE-AB) project, this study aimed to identify key elements for a global definition of responsible antibiotic use based on diverse stakeholder input.

Methods

A three-step RAND-modified Delphi method was applied. First, a systematic review of antibiotic stewardship literature and relevant organization web sites identified definitions and synonyms of responsible use. Identified elements of definitions were presented by questionnaire to a multidisciplinary international stakeholder panel for appraisal of their relevance. Finally, questionnaire results were discussed in a consensus meeting.

Results

The systematic review and the web site search identified 17 synonyms (e.g. appropriate, correct) and 22 potential elements to include in a definition of responsible use. Elements were grouped into patient-level (e.g. Indication, Documentation) or societal-level elements (e.g. Education, Future Effectiveness). Forty-eight stakeholders with diverse backgrounds [medical community, public health, patients, antibiotic research and development (R&D), regulators, governments] from 18 countries across all continents participated in the questionnaire. Based on relevance scores, 21 elements were retained, 9 were rephrased and 1 was added. Together, the 22 elements and associated best-practice descriptions comprise an exhaustive list of elements to be considered when defining responsible use.

Conclusions

Combination of concepts from the literature and stakeholder opinion led to an international multidisciplinary consensus on a global definition of responsible antibiotic use. The widely diverging perspectives of stakeholders providing input should ensure the comprehensiveness and relevance of the definition for both individual patients and society. An aspirational goal would be to address all elements.

Thai clinicians' attitudes toward antimicrobial stewardship programs

BACKGROUND

Effective hospital-wide antimicrobial stewardship (AMS) programs need multidisciplinary engagement; however, clinicians' attitudes have not been investigated in Thailand where AMS is in early development. The aim of this study was to explore Thai clinicians' (doctors, nurses, and pharmacists) perceptions and attitudes toward AMS.

METHODS

A paper-based survey was distributed in a 1,000-bed university hospital in Bangkok, Thailand, between November 9, 2015, and December 21, 2015. A total of 1,087 clinicians participated: 392 doctors, 613 nurses, and 82 pharmacists.

RESULTS

Most participants agreed that improving antimicrobial prescribing would decrease antimicrobial resistance (AMR) and should be a priority of hospital policy. Doctors were less likely to agree with policies that limit antimicrobial prescribing (P < .001) than nurses or pharmacists, and were less likely to be interested in participating in AMS education than other clinicians (P < .001). Pharmacists indicated higher agreement with the statement, recommending that a specialist team provide individualized antimicrobial prescribing advice (P < .01) and that feedback improves antimicrobial selection (P < .001). Nurses were less likely to agree that community antibiotic use (P < .001) or patient pressure for antibiotics contribute to AMR (P < .001).

CONCLUSIONS

AMS programs are vital to improving antimicrobial use by clinicians. Understanding clinicians' attitudes and perceptions related to AMS is important to ensure that AMS programs developed address areas relevant to local clinical needs.

A review of antimicrobial stewardship training in medical education

OBJECTIVES

We reviewed the published literature on antimicrobial stewardship training in undergraduate and postgraduate medical education to determine which interventions have been implemented, the extent to which they have been evaluated, and to understand which are most effective.

METHODS

We searched Ovid MEDLINE and EMBASE from inception to December 2016. Four thousand three hundred eighty-five (4385) articles were identified and underwent title and abstract review. Only those articles that addressed antimicrobial stewardship interventions for medical trainees were included in the final review. We employed Kirkpatrick's four levels of evaluation (reaction, learning, behaviour, results) to categorize intervention evaluations.

RESULTS

Our review included 48 articles. The types of intervention varied widely amongst studies worldwide. Didactic teaching was used heavily in all settings, while student-specific feedback was used primarily in the postgraduate setting. The high-level evaluation was sparse, with 22.9% reporting a Kirkpatrick Level 3 evaluation; seventeen reported no evaluation. All but one article reported positive results from the intervention. No articles evaluated the impact of an intervention on undergraduate trainees' prescribing behaviour after graduation.

CONCLUSIONS

This study enhances our understanding of the extent of antimicrobial stewardship in the context of medical education. While our study demonstrates that medical schools are implementing antimicrobial stewardship interventions, rigorous evaluation of programs to determine whether such efforts are effective is lacking. We encourage more robust evaluation to establish effective, evidence-based approaches to training prescribers in light of the global challenge of antimicrobial resistance.

Behavioral Approach to Appropriate Antimicrobial Prescribing in Hospitals: The Dutch Unique Method for Antimicrobial Stewardship (DUMAS) Participatory Intervention Study

Importance

Inappropriate antimicrobial prescribing leads to antimicrobial resistance and suboptimal clinical outcomes. Changing antimicrobial prescribing is a complex behavioral process that is not often taken into account in antimicrobial stewardship programs.

Objective

To examine whether an antimicrobial stewardship approach grounded in behavioral theory and focusing on preserving prescriber autonomy and participation is effective in improving appropriateness of antimicrobial prescribing in hospitals.

Design, Setting, and Participants

The Dutch Unique Method for Antimicrobial Stewardship (DUMAS) study was a prospective, stepped-wedge, participatory intervention study performed from October 1, 2011, through December 31, 2015. Outcomes were measured during a baseline period of 16 months and an intervention period of 12 months. The study was performed at 7 clinical departments (2 medical, 3 surgical, and 2 pediatric) in a tertiary care medical center and a general teaching hospital in the Netherlands. Physicians prescribing systemic antimicrobial drugs for any indication for patients admitted to the participating departments during the study period were included in the study.

Interventions

We offered prescribers a free choice of how to improve their antimicrobial prescribing. Prescribers were stimulated to choose interventions with higher potential for success based on a root cause analysis of inappropriate prescribing.

Main Outcomes and Measures

Appropriateness of antimicrobial prescriptions was determined using a validated approach based on guideline adherence and motivated guideline deviation and measured with repeated point prevalence surveys (6 per year). Appropriateness judgment was masked for the study period. Antimicrobial consumption was extracted from pharmacy records and measured as days of therapy per admission. We used linear and logistic mixed-model regression analysis to model outcomes over time.

Results

A total of 1121 patient cases with 700 antimicrobial prescriptions were assessed during the baseline period and 882 patient cases with 531 antimicrobial prescriptions during the intervention period. The mean antimicrobial appropriateness increased from 64.1% at intervention start to 77.4% at 12-month follow-up (+13.3%; relative risk, 1.17; 95% CI, 1.04-1.27), without a change in slope. No decrease in antimicrobial consumption was found.

Conclusions and Relevance

Use of a behavioral approach preserving prescriber autonomy resulted in an increase in antimicrobial appropriateness sustained for at least 12 months. The approach is inexpensive and could be easily transferable to various health care environments.

Barriers to uptake of antimicrobial advice in a UK hospital: a qualitative study

BACKGROUND

The role of infectious diseases (ID) and clinical microbiology (CM) in hospital settings has expanded in response to increasing antimicrobial resistance, leading to widespread development of hospital antimicrobial stewardship (AMS) programmes, the majority of which include antibiotic approval systems. However, inappropriate antibiotic use in hospitals continues, suggesting potential disjunctions between technical advice and the logics of antibiotic use within hospitals.

AIM

To examine the experiences of doctors in a UK hospital with respect to AMS guidance of antibiotic prescribing, and experiences of a verbal postprescription antibiotic approval process.

METHODS

Twenty doctors in a teaching hospital in the UK participated in semi-structured interviews about their experiences of antibiotic use and governance. NVivo10 software was used to conduct a thematic content analysis systematically.

FINDINGS

This study identified three key themes regarding doctors' relationships with ID/CM clinicians that shaped their antibiotic practices: (1) competing hierarchical influences limiting active consultation with ID/CM; (2) non-ID/CM consultants' sense of ownership over clinical decision-making and concerns about challenges to clinical autonomy; and (3) tensions between evidence-based practice and experiential-style learning.

CONCLUSIONS

This study illustrates the importance of examining relations between ID/CM and non-ID/CM clinicians in the hospital context, indicating that AMS models that focus exclusively on delivering advice rather than managing interprofessional relationships may be limited in their capacity to optimize antibiotic use. AMS and, specifically, antibiotic approval systems would likely be more effective if they incorporated time and resources for fostering and maintaining professional relationships.

Administration of a survey to evaluate the attitudes of house staff physicians towards antimicrobial resistance and the antimicrobial stewardship programme at a community teaching hospital

Antimicrobial stewardship programmes (ASPs) are used in numerous institutions in an effort to promote safe and effective antimicrobial use. The objectives of this study were to (i) assess physicians' perceptions, attitudes and knowledge about antimicrobial use, resistance and the ASP at The Brooklyn Hospital Center (TBHC) and (ii) measure physicians' beliefs and attitudes to the current system of prior authorisation of antimicrobials. A 75-item, anonymous, voluntary, traditional paper and pencil survey was distributed to resident physicians at TBHC. Multiple-choice, 5-point Likert scale and knowledge-based questions were utilised. Of the 261 residents, 129 (49%) completed the survey. The respondents significantly believed that antibiotics are overused more frequently nationally vs. locally [117/129 (91%) vs. 91/129 (71%); P=0.0001]. Although 49% (63/129) felt that other providers overprescribe antibiotics, only 26% (34/129) agreed that they themselves were contributing to the current problem (P=0.0003). Fifty-seven percent of respondents agreed that individual patient care is improved by having an antibiotic approval programme; however, 45% of respondents reported that the antibiotic approval programme limits their autonomy in choosing antibiotics. Compared with surgical residents, medical residents were more likely (33% vs. 13%; P=0.02) to feel that the antibiotic approval programme forced them to choose an inappropriate antibiotic. On the antibiotic knowledge assessment segment of the survey, there was no difference in score when stratified by specialty or years of postgraduate training. Based on the survey results, house staff are supportive of antimicrobial stewardship and feel that the ASP is valuable for patient care.

Antibiotic use in US hospitals: quantification, quality measures and stewardship

A majority of patients hospitalized in the US hospitals receive an antibiotic during their hospitalization. Furthermore, up to half of antibiotics prescribed in hospitals are inappropriate. In the setting of continued emergence of antibiotic-resistant pathogens and a limited pipeline of new antimicrobials, attention to optimizing antibiotic use in healthcare settings is essential. We review the measures of antibiotic consumption in the USA, the evolving metrics for comparing antibiotic use (known as benchmarking), trends in antibiotic use, the structure and outcome measures of Antimicrobial Stewardship Programs and interventions to optimize antimicrobial use.

Analysis of knowledge and attitude surveys to identify barriers and enablers of appropriate antimicrobial prescribing in three Australian tertiary hospitals

BACKGROUND

Antimicrobial stewardship programmes aim to optimise use of antibiotics and are now mandatory in all Australian hospitals.

AIM

We aimed to identify barriers to and enablers of appropriate antimicrobial prescribing among hospital doctors.

METHODS

Two paper-based and one web-based surveys were administered at three Australian university teaching hospitals from March 2010 to May 2011. The 18-item questionnaire recorded doctors’ level of experience, their knowledge regarding the use of common antimicrobials and their attitudes regarding antimicrobial prescribing. Local survey modifications allowed inclusion of specific questions on: infections in intensive care unit patients, clinical microbiology and use of local guidelines.

RESULTS

The respondents (n = 272) were comprised of 96 (35%) registrars, 67 (25%)residents, 57 (21%) interns and 47 (17%) consultant hospital doctors. Forty-one per cent were working in a medical specialty. Identified barriers included: gaps in antimicrobial prescribing knowledge (especially among interns), a lack of awareness about which antimicrobials were restricted and a reliance on senior colleagues to make antimicrobial prescribing decisions. Enablers of optimal prescribing included: an acknowledgement of the need for assistance in prescribing and reported readiness to consult national prescribing guidelines. These results were used to help guide and prioritise interventions to improve prescribing practices.

CONCLUSION

A transferable knowledge and attitudes survey tool can be used to highlight barriers and facilitators to optimal hospital antimicrobial prescribing in order to inform tailored antimicrobial stewardship interventions.

Clinicians' Attitudes Towards an Antimicrobial Stewardship Program at a Children's Hospital

BACKGROUND

In pediatrics, limited data are available on how to develop and implement an antimicrobial stewardship program (ASP). In addition, no data exist on clinicians' impression of such programs. The objectives of this study were to describe the development and implementation of an ASP in a children's hospital and to describe the thoughts and attitudes of the clinicians interacting with the ASP.

METHODS

A qualitative description of the development and implementation of an ASP is provided. In addition, 2 years after the implementation of a prospective-audit-with-feedback ASP, an electronic survey was administered to clinicians to assess their attitudes toward the ASP.

RESULTS

A 5-step process for developing this ASP included the following: team development; selecting the stewardship strategy(ies) and antimicrobials to monitor; establishing a method to identify patients; program evaluation; and implementation. Of 365 participants surveyed, 205 (56%) responded, and 80% (160 of 199) had never worked with an ASP before its implementation. Clinicians agreed that the ASP decreased inappropriate use of antibiotics (84%, 162 of 194), improved the quality of patient care (82%, 159 of 194), and provided knowledge and education about appropriate antibiotic use (91%, 177 of 194). Negative feelings regarding the ASP included the following: 11% (22 of 194) felt a loss of autonomy; 6% (12 of 194) felt that it interfered with clinical decision-making; and 5% (9 of 194) felt threatened. Clinicians thought that to further decrease inappropriate antibiotic use, guidelines of empiric antibiotic choices (80%, 152 of 189) should be developed, and better training in medical school and residency should be provided (80%, 152 of 189). Finally, our clinicians felt that the problem of antibiotic resistance and inappropriate antibiotic use was worse nationally than at our institution.

CONCLUSIONS

A prospective-audit-with-feedback ASP was successfully developed and implemented at a children's hospital. The ASP was perceived by clinicians to reduce inappropriate antibiotic use and to improve the quality of care of hospitalized children, with minimal loss of physician autonomy or interference in clinical decision-making.

Improving antimicrobial stewardship: the evolution of programmatic strategies and barriers

OBJECTIVE

To describe the prevalence and characteristics of antimicrobial stewardship programs (ASPs) in hospitals across the United States and to describe financial support provided for these programs.

DESIGN

Electronic and paper 14-question survey of infectious diseases physician members of the Infectious Diseases Society of America Emerging Infections Network (IDSA EIN).

PARTICIPANTS

All 1,044 IDSA EIN members who care for adult patients were invited to participate.

RESULTS

Five hundred twenty-two (50%) members responded. Seventy-three percent of respondents reported that their institutions had or were planning an ASP, compared with 50% reporting the same thing in an EIN survey 10 years before. A shift was noted from formulary restriction alone to use of a set of tailored strategies designed to provide information and feedback to prescribers, particularly in community hospitals. Lack of funding and lack of personnel were reported as major barriers to implementing a program. Fifty-two percent of respondents with an ASP reported that infectious diseases physicians do not receive direct compensation for their participation in the ASP, compared with 18% 10 years ago.

CONCLUSIONS

The percentage of institutions reporting ASPs has increased over the last decade, although small community hospitals were least likely to have these programs. In addition, ASP strategies have shifted dramatically. Lack of funding remains a key barrier for ASPs, and administrators need additional cost savings data in order to support ASPs. Interestingly, while guidelines and editorials regard compensated participation by an infectious diseases physician in these programs as critical, we found that more than half of the respondents reported no direct compensation for ASP activities.

[Bacterial resistance and antibiotic prescription: a survey of hospital physician perception, attitude, and knowledge]

OBJECTIVE

The authors' goal was to assess physicians' perception of antibiotic prescribing practice and of bacterial resistance.

DESIGN

We questioned 503 interns and senior physicians in the Nice University Hospital.

RESULTS

Three hundred and twenty-two out of five hundred and three (64 %) physicians answered the questionnaire. Antibiotic resistance was perceived as a national problem by 98 % of physicians, but only 74 % rated the problem as important in their own daily practice. Fifty-nine percent of interns and 34 % of senior physicians respectively had received some training on antibiotic prescribing in the past 12 months. Only 33 % of physicians knew the exact prevalence of MRSA in their hospital. Senior physicians were more confident than interns when prescribing an antibiotic. The three issues they were the less confident with were: indications of antibiotic combinations, reassessment, and duration of antibiotic treatment. They were aware that antibiotic overuse, prescription of broad-spectrum molecules, or subtherapeutic doses of antibiotics were the three major causes of antibiotic resistance. They believed that the most useful measures to improve antibiotic prescription were: availability of guidelines, specific courses, readily accessible advice from an infectious diseases specialist, and audit plus feedback.

CONCLUSIONS

The collected data provides useful information for the implementation of strategies to optimize adherence to good antimicrobial stewardship.

Junior doctors' knowledge and perceptions of antibiotic resistance and prescribing: a survey in France and Scotland

Our objective was to assess junior doctors' perceptions of their antibiotic prescribing practice and of bacterial resistance. We surveyed 190 postgraduate doctors still in training at two university teaching hospitals, in Nice (France) and Dundee (Scotland, UK), and 139 of them (73%) responded to the survey. The main results presented in this abstract are combined for Nice and Dundee, because there was no statistical difference for these points between the two hospitals. Antibiotic resistance was perceived as a national problem by 95% of the junior doctors, but only 63% rated the problem as important in their own daily practice. Their perceptions of the causes of antibiotic resistance were sometimes at variance with available medical evidence, with excessive duration of antibiotic treatment and poor hand hygiene practices rarely being perceived as important drivers for resistance. Only 31% and 26% of the doctors knew the correct prevalences of antibiotic misuse and of methicillin-resistant Staphylococcus aureus in hospitals, respectively. They preferred educational interventions, such as specific teaching sessions, availability of guidelines or readily accessible advice from an infectious diseases specialist, to improve antibiotic prescribing, rather than restricted prescription of antibiotics. These data provide helpful information for the design of strategies to optimize adherence to good antimicrobial stewardship.