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Unroe KT, Saliba D, Hickman SE, Zimmerman S, Levy C, Gurwitz J. Evaluation of medical therapies in the nursing home population: Gaps, challenges, and next steps. J Am Geriatr Soc 2024; 72:2951-2956. [PMID: 38485449 DOI: 10.1111/jgs.18829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 01/02/2024] [Indexed: 09/03/2024]
Affiliation(s)
- Kathleen T Unroe
- Division of General Internal Medicine and Geriatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Indiana University Center for Aging Research, Regenstrief Institute Inc., Indianapolis, Indiana, USA
- Research in Palliative and End-of-Life Communication and Training (RESPECT) Center, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Debra Saliba
- US Department of Veterans Affairs Greater Los Angeles Healthcare System (VAGLAS) Health Services Research and Development Service (HSR&D) Center of Innovation, Los Angeles, California, USA
- David Geffen School of Medicine, University of California, Los Angeles, California, USA
- Anna and Harry Borun Center for Gerontological Research, University of California Division of Geriatrics, Los Angeles, California, USA
- RAND Corporation, Santa Monica, California, USA
| | - Susan E Hickman
- Indiana University Center for Aging Research, Regenstrief Institute Inc., Indianapolis, Indiana, USA
- Research in Palliative and End-of-Life Communication and Training (RESPECT) Center, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Indiana University School of Nursing, Indianapolis, Indiana, USA
| | - Sheryl Zimmerman
- School of Social Work, University of North Carolina, Chapel Hill, North Carolina, USA
- Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina, USA
- Center for Excellence in Assisted Living (CEAL), School of Social Work, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Cari Levy
- Division of Geriatric Medicine, University of Colorado School of Medicine Anschutz Campus, Aurora, Colorado, USA
- Denver Veterans Affairs Medical Center, Aurora, Colorado, USA
| | - Jerry Gurwitz
- Division of Geriatric Medicine, UMass Chan Medical School, Worcester, Massachusetts, USA
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Vicentini C, Libero G, Cugudda E, Gardois P, Zotti CM, Bert F. Barriers to the implementation of antimicrobial stewardship programmes in long-term care facilities: a scoping review. J Antimicrob Chemother 2024; 79:1748-1761. [PMID: 38870077 PMCID: PMC11290887 DOI: 10.1093/jac/dkae146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2024] Open
Abstract
BACKGROUND Long-term care facilities (LTCFs) present specific challenges for the implementation of antimicrobial stewardship (AMS) programmes. A growing body of literature is dedicated to AMS in LTCFs. OBJECTIVES We aimed to summarize barriers to the implementation of full AMS programmes, i.e. a set of clinical practices, accompanied by recommended change strategies. METHODS A scoping review was conducted through Ovid-MEDLINE, CINAHL, Embase and Cochrane Central. Studies addressing barriers to the implementation of full AMS programmes in LTCFs were included. Implementation barriers described in qualitative studies were identified and coded, and main themes were identified using a grounded theory approach. RESULTS The electronic search revealed 3904 citations overall. Of these, 57 met the inclusion criteria. All selected studies were published after 2012, and the number of references per year progressively increased, reaching a peak in 2020. Thematic analysis of 13 qualitative studies identified three main themes: (A) LTCF organizational culture, comprising (A1) interprofessional tensions, (A2) education provided in silos, (A3) lack of motivation and (A4) resistance to change; (B) resources, comprising (B1) workload and staffing levels, (B2) diagnostics, (B3) information technology resources and (B4) funding; and (C) availability of and access to knowledge and skills, including (C1) surveillance data, (C2) infectious disease/AMS expertise and (C3) data analysis skills. CONCLUSIONS Addressing inappropriate antibiotic prescribing in LTCFs through AMS programmes is an area of growing interest. Hopefully, this review could be helpful for intervention developers and implementers who want to build on the most recent evidence from the literature.
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Affiliation(s)
- Costanza Vicentini
- Department of Public Health Sciences and Pediatrics, University of Turin, Torino, Italy
| | - Giulia Libero
- Department of Public Health Sciences and Pediatrics, University of Turin, Torino, Italy
| | - Eleonora Cugudda
- Department of Public Health Sciences and Pediatrics, University of Turin, Torino, Italy
| | - Paolo Gardois
- Department of Public Health Sciences and Pediatrics, Medical Library ‘Ferdinando Rossi’, University of Turin, Torino, Italy
| | - Carla Maria Zotti
- Department of Public Health Sciences and Pediatrics, University of Turin, Torino, Italy
| | - Fabrizio Bert
- Department of Public Health Sciences and Pediatrics, University of Turin, Torino, Italy
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Ayorinde A, Ghosh I, Shaikh J, Adetunji V, Brown A, Jordan M, Gilham E, Todkill D, Ashiru-Oredope D. Improving healthcare professionals' interactions with patients to tackle antimicrobial resistance: a systematic review of interventions, barriers, and facilitators. Front Public Health 2024; 12:1359790. [PMID: 38841670 PMCID: PMC11150712 DOI: 10.3389/fpubh.2024.1359790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 04/30/2024] [Indexed: 06/07/2024] Open
Abstract
Introduction Antimicrobial resistance (AMR) is a major public health threat. With the growing emphasis on patient-centred care/ shared decision making, it is important for healthcare professionals' (HCPs) who prescribe, dispense, administer and/or monitor antimicrobials to be adequately equipped to facilitate appropriate antimicrobial use. We systematically identified existing interventions which aim to improve HCPs interaction with patients and examined barriers and facilitators of appropriate the use of such interventions and appropriate antimicrobial use among both HCPs and patientsantimicrobial use while using these interventions. Methods We searched MEDLINE, EMBASE, Web of Science, Google Scholar, and internet (via Google search engine). We included primary studies, published in English from 2010 to 2023 [PROSPERO (CRD42023395642)]. The protocol was preregistered with PROSPERO (CRD42023395642). We performed quality assessment using mixed methods appraisal tool. We applied narrative synthesis and used the COM-B (Capability, Opportunity, Motivation -Behaviour) as a theoretical framework for barriers and facilitators at HCP and patient levels. Results Of 9,172 citations retrieved from database searches, From 4,979 citations remained after removal of duplicates. We included 59 studies spanning over 13 countries. Interventions often involved multiple components beyond HCPs' interaction with patients. From 24 studies reporting barriers and facilitators, we identified issues relating to capability (such as, knowledge/understanding about AMR, diagnostic uncertainties, awareness of interventions and forgetfulness); opportunity (such as, time constraint and intervention accessibility) and motivation (such as, patient's desire for antibiotics and fear of litigation). Conclusion The findings of this review should be considered by intervention designers/adopters and policy makers to improve utilisation and effectiveness.
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Affiliation(s)
- Abimbola Ayorinde
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Iman Ghosh
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Junaid Shaikh
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Victoria Adetunji
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Anna Brown
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Mary Jordan
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Ellie Gilham
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Daniel Todkill
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Diane Ashiru-Oredope
- UK Health Security Agency, London, United Kingdom
- School of Pharmacy, University of Nottingham, Nottingham, United Kingdom
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Conlin M, Hamard M, Agrinier N, Birgand G. Assessment of implementation strategies adopted for antimicrobial stewardship interventions in long-term care facilities: a systematic review. Clin Microbiol Infect 2024; 30:431-444. [PMID: 38141820 DOI: 10.1016/j.cmi.2023.12.020] [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: 07/24/2023] [Revised: 12/11/2023] [Accepted: 12/17/2023] [Indexed: 12/25/2023]
Abstract
BACKGROUND The implementation of antimicrobial stewardship (AMS) interventions in long-term care facilities (LTCFs) is influenced by multi-level factors (resident, organizational, and external) making their effectiveness sensitive to the implementation context. OBJECTIVES This study assessed the strategies adopted for the implementation of AMS interventions in LTCFs, whether they considered organizational characteristics, and their effectiveness. DATA SOURCES Electronic databases until April 2022. STUDY ELIGIBILITY CRITERIA Articles covering implementation of AMS interventions in LTCFs. ASSESSMENT OF RISK OF BIAS Mixed Methods Appraisal Tool for empirical studies. METHODS OF DATA SYNTHESIS Data were collected on AMS interventions and context characteristics (e.g. type of facility, staffing, and residents). Implementation strategies and outcomes were mapped according to the Expert Recommendations for Implementing Change (ERIC) framework and validated taxonomy for implementation outcomes. Implementation and clinical effectiveness were assessed according to the primary and secondary outcomes results provided in each study. RESULTS Among 48 studies included in the analysis, 19 (40%) used implementation strategies corresponding to one to three ERIC domains, including education and training (n = 36/48, 75%), evaluative and iterative strategies (n = 24/48, 50%), and support clinicians (n = 23/48, 48%). Only 8/48 (17%) studies made use of implementation theories, frameworks, or models. Fidelity and sustainability were reported respectively in 21 (70%) and 3 (10%) of 27 studies providing implementation outcomes. Implementation strategy was considered effective in 11/27 (41%) studies, mainly including actions to improve use (n = 6/11, 54%) and education (n = 4/11, 36%). Of the 42 interventions, 18/42 (43%) were deemed clinically effective. Among 21 clinically effective studies, implementation was deemed effective in four and partially effective in five. Two studies were clinically effective despite having non-effective implementation. CONCLUSIONS The effectiveness of AMS interventions in LTCFs largely differed according to the interventions' content and implementation strategies adopted. Implementation frameworks should be considered to adapt and tailor interventions and strategies to the local context.
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Affiliation(s)
- Michèle Conlin
- Regional Center for Infection Prevention and Control Pays de la Loire, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Marie Hamard
- Unité de gériatrie Aiguë, Hôpital Bichat-Claude Bernard, Paris, France
| | - Nelly Agrinier
- Université de Lorraine, Inserm, INSPIIRE, F-54000 Nancy, France; CHRU-Nancy, Inserm, Université de Lorraine, CIC, Epidémiologie clinique, Nancy, France.
| | - Gabriel Birgand
- Regional Center for Infection Prevention and Control Pays de la Loire, Centre Hospitalier Universitaire de Nantes, Nantes, France; National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance at Imperial College London, London, UK
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Bocquier A, Erkilic B, Babinet M, Pulcini C, Agrinier N. Resident-, prescriber-, and facility-level factors associated with antibiotic use in long-term care facilities: a systematic review of quantitative studies. Antimicrob Resist Infect Control 2024; 13:29. [PMID: 38448955 PMCID: PMC10918961 DOI: 10.1186/s13756-024-01385-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 02/29/2024] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND Antimicrobial stewardship programmes are needed in long-term care facilities (LTCFs) to tackle antimicrobial resistance. We aimed to identify factors associated with antibiotic use in LTCFs. Such information would be useful to guide antimicrobial stewardship programmes. METHOD We conducted a systematic review of studies retrieved from PubMed, Cochrane Library, Embase, APA PsycArticles, APA PsycINFO, APA PsycTherapy, ScienceDirect and Web of Science. We included quantitative studies that investigated factors associated with antibiotic use (i.e., antibiotic prescribing by health professionals, administration by LTCF staff, or use by residents). Participants were LTCF residents, their family, and/or carers. We performed a qualitative narrative synthesis of the findings. RESULTS Of the 7,591 screened records, we included 57 articles. Most studies used a longitudinal design (n = 34/57), investigated resident-level (n = 29/57) and/or facility-level factors (n = 32/57), and fewer prescriber-level ones (n = 8/57). Studies included two types of outcome: overall volume of antibiotic prescriptions (n = 45/57), inappropriate antibiotic prescription (n = 10/57); two included both types. Resident-level factors associated with a higher volume of antibiotic prescriptions included comorbidities (5 out of 8 studies which investigated this factor found a statistically significant association), history of infection (n = 5/6), potential signs of infection (e.g., fever, n = 4/6), positive urine culture/dipstick results (n = 3/4), indwelling urinary catheter (n = 12/14), and resident/family request for antibiotics (n = 1/1). At the facility-level, the volume of antibiotic prescriptions was positively associated with staff turnover (n = 1/1) and prevalence of after-hours medical practitioner visits (n = 1/1), and negatively associated with LTCF hiring an on-site coordinating physician (n = 1/1). At the prescriber-level, higher antibiotic prescribing was associated with high prescription rate for antibiotics in the previous year (n = 1/1). CONCLUSIONS Improving infection prevention and control, and diagnostic practices as part of antimicrobial stewardship programmes remain critical steps to reduce antibiotic prescribing in LTCFs. Once results confirmed by further studies, implementing institutional changes to limit staff turnover, ensure the presence of a professional accountable for the antimicrobial stewardship activities, and improve collaboration between LTCFs and external prescribers may contribute to reduce antibiotic prescribing.
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Affiliation(s)
- Aurélie Bocquier
- Université de Lorraine, Inserm, INSPIIRE, Nancy, F-54000, France.
| | - Berkehan Erkilic
- Université de Lorraine, Inserm, INSPIIRE, Nancy, F-54000, France
| | - Martin Babinet
- CHRU-Nancy, INSERM, Université de Lorraine, CIC, Epidémiologie clinique, Nancy, F-54000, France
| | - Céline Pulcini
- Université de Lorraine, Inserm, INSPIIRE, Nancy, F-54000, France
- Centre régional en antibiothérapie du Grand Est AntibioEst, Université de Lorraine, CHRU-Nancy, Nancy, F-54000, France
| | - Nelly Agrinier
- Université de Lorraine, Inserm, INSPIIRE, Nancy, F-54000, France
- CHRU-Nancy, INSERM, Université de Lorraine, CIC, Epidémiologie clinique, Nancy, F-54000, France
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Peñalva G, Crespo-Rivas JC, Guisado-Gil AB, Rodríguez-Villodres Á, Pachón-Ibáñez ME, Cachero-Alba B, Rivas-Romero B, Gil-Moreno J, Galvá-Borras MI, García-Moreno M, Salamanca-Bautista MD, Martínez-Rascón MB, Cantudo-Cuenca MR, Ninahuaman-Poma RC, Enrique-Mirón MDLÁ, Pérez-Barroso A, Marín-Ariza I, González-Florido M, Mora-Santiago MDR, Belda-Rustarazo S, Expósito-Tirado JA, Rosso-Fernández CM, Gil-Navarro MV, Lepe-Jiménez JA, Cisneros JM. Clinical and Ecological Impact of an Educational Program to Optimize Antibiotic Treatments in Nursing Homes (PROA-SENIOR): A Cluster, Randomized, Controlled Trial and Interrupted Time-Series Analysis. Clin Infect Dis 2023; 76:824-832. [PMID: 36268822 PMCID: PMC9619844 DOI: 10.1093/cid/ciac834] [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: 07/22/2022] [Revised: 10/05/2022] [Accepted: 10/18/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Antimicrobial stewardship programs (ASPs) are recommended in nursing homes (NHs), although data are limited. We aimed to determine the clinical and ecological impact of an ASP for NHs. METHODS We performed a cluster, randomized, controlled trial and a before-after study with interrupted time-series analyses in 14 NHs for 30 consecutive months from July 2018 to December 2020 in Andalusia, Spain. Seven facilities implemented an ASP with a bundle of 5 educational measures (general ASP) and 7 added 1-to-1 educational interviews (experimental ASP). The primary outcome was the overall use of antimicrobials, calculated monthly as defined daily doses (DDD) per 1000 resident days (DRD). RESULTS The total mean antimicrobial consumption decreased by 31.2% (-16.72 DRD; P = .045) with respect to the preintervention period; the overall use of quinolones and amoxicillin-clavulanic acid dropped by 52.2% (P = .001) and 42.5% (P = .006), respectively; and the overall prevalence of multidrug-resistant organisms (MDROs) decreased from 24.7% to 17.4% (P = .012). During the intervention period, 12.5 educational interviews per doctor were performed in the experimental ASP group; no differences were found in the total mean antimicrobial use between groups (-14.62 DRD; P = .25). Two unexpected coronavirus disease 2019 waves affected the centers increasing the overall mean use of antimicrobials by 40% (51.56 DRD; P < .0001). CONCLUSIONS This study suggests that an ASP for NHs appears to be associated with a decrease in total consumption of antimicrobials and prevalence of MDROs. This trial did not find benefits associated with educational interviews, probably due to the coronavirus disease 2019 pandemic. Clinical Trials Registration. NCT03543605.
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Affiliation(s)
- Germán Peñalva
- Department of Infectious Diseases, Microbiology and Parasitology, Institute of Biomedicine of Seville, University Hospital Virgen del Rocío, Spanish National Research Council, University of Seville, Spain
| | - Juan Carlos Crespo-Rivas
- Department of Infectious Diseases, Microbiology and Parasitology, Institute of Biomedicine of Seville, University Hospital Virgen del Rocío, Spanish National Research Council, University of Seville, Spain
| | - Ana Belén Guisado-Gil
- Department of Infectious Diseases, Microbiology and Parasitology, Institute of Biomedicine of Seville, University Hospital Virgen del Rocío, Spanish National Research Council, University of Seville, Spain.,Department of Pharmacy, University Hospital Virgen del Rocío, Seville, Spain.,CIBERINFECT, Center for Biomedical Research Network on Infectious Diseases, Madrid, Spain
| | - Ángel Rodríguez-Villodres
- Department of Infectious Diseases, Microbiology and Parasitology, Institute of Biomedicine of Seville, University Hospital Virgen del Rocío, Spanish National Research Council, University of Seville, Spain
| | - María Eugenia Pachón-Ibáñez
- Department of Infectious Diseases, Microbiology and Parasitology, Institute of Biomedicine of Seville, University Hospital Virgen del Rocío, Spanish National Research Council, University of Seville, Spain.,CIBERINFECT, Center for Biomedical Research Network on Infectious Diseases, Madrid, Spain
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - María Victoria Gil-Navarro
- Department of Pharmacy, University Hospital Virgen del Rocío, Seville, Spain.,CIBERINFECT, Center for Biomedical Research Network on Infectious Diseases, Madrid, Spain
| | - José Antonio Lepe-Jiménez
- Department of Infectious Diseases, Microbiology and Parasitology, Institute of Biomedicine of Seville, University Hospital Virgen del Rocío, Spanish National Research Council, University of Seville, Spain.,CIBERINFECT, Center for Biomedical Research Network on Infectious Diseases, Madrid, Spain
| | - José Miguel Cisneros
- Department of Infectious Diseases, Microbiology and Parasitology, Institute of Biomedicine of Seville, University Hospital Virgen del Rocío, Spanish National Research Council, University of Seville, Spain.,CIBERINFECT, Center for Biomedical Research Network on Infectious Diseases, Madrid, Spain
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Singh S, Degeling C, Fernandez D, Montgomery A, Caputi P, Deane FP. How do aged-care staff feel about antimicrobial stewardship? A systematic review of staff attitudes in long-term residential aged-care. Antimicrob Resist Infect Control 2022; 11:92. [PMID: 35765093 PMCID: PMC9238058 DOI: 10.1186/s13756-022-01128-5] [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: 02/04/2022] [Accepted: 06/11/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Antimicrobial resistance (AMR) is a problem in residential aged care facilities (RACF). There is a gap in our understanding of how psychosocial barriers such as risk perceptions shape staff attitudes towards antimicrobial stewardship (AMS). We sought to ascertain the attitudinal domains that have been identified to be of importance to AMS in RACF and comment on how they have been measured empirically. Our aim was to consolidate what is known regarding staff attitudes and perceptions in order to inform future stewardship.
Method
We searched PsycINFO, PsycARTICLES, CINAHL Plus, MEDLINE, PubMed, Web of Science, Cochrane, and Scopus databases for primary studies of healthcare workers attitudes to AMS in RACF (1990-February 2021).
Results
14 Studies were included in the review, within which 10 domains were identified: attitudes towards antimicrobial prescribing; guidelines; educational interventions; self-confidence regarding clinical assessment and prescribing; awareness of AMR as a problem and stewardship as a priority; self-efficacy; perception of role; perception of risk; team culture and resident/family members expectations. 46 measures were developed across the 14 studies to measure the 10 domains. The variability in the attitudinal domains and how these domains were measured was large. Only 13% included psychometric data regarding reliability and/or internal consistency.
Conclusions
Attitudes are generally defined as having three evaluative bases: cognitive, behavioural, and affective. Findings from the current review suggest that the measures commonly used to capture healthcare staff attitudes to AMS do not sufficiently capture affect; particularly with respect to staff’s risk perceptions, perceptions of their role, and family members’ expectations. Given that affective processes have been postulated to influence medical decision making, these findings highlight the importance of understanding how staff, especially nurses feel about implementing AMS strategies and other peoples’ (e.g. residents and their families) perceptions of stewardship. It is expected that a more nuanced understanding of RACF nurses affective experiences when applying AMS, and their perceptions of the risks entailed, will help in reducing barriers to overprescribing antibiotics.
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Cook DA, Wilkinson JM, Foo J. Costs of Physician Continuous Professional Development: A Systematic Review. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2022; 97:1554-1563. [PMID: 35830262 DOI: 10.1097/acm.0000000000004805] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
PURPOSE An essential yet oft-neglected step in cost evaluations is the selection of resources (ingredients) to include in cost estimates. The ingredients that most influence the cost of physician continuous professional development (CPD) are unknown, as are the relative costs of instructional modalities. This study's purpose was to estimate the costs of cost ingredients and instructional modalities in physician CPD. METHOD The authors conducted a systematic review in April 2020, searching MEDLINE, Embase, PsycInfo, and the Cochrane Library for comparative cost evaluations of CPD for practicing physicians. Two reviewers, working independently, screened articles for inclusion and extracted information on costs (converted to 2021 U.S. dollars) for each intervention overall, each ingredient, and each modality. RESULTS Of 3,338 eligible studies, 62 were included, enumerating costs for 86 discrete training interventions or instructional modalities. The most frequently reported ingredients were faculty time (25 of 86 interventions), materials (24), administrator/staff time (23), and travel (20). Ingredient costs varied widely, ranging from a per-physician median of $4 for postage (10 interventions) to $525 for learner time (13); equipment (9) and faculty time were also relatively expensive (median > $170). Among instructional modalities (≤ 11 interventions per modality), audit and feedback performed by physician learners, computer-based modules, computer-based virtual patients, in-person lectures, and experiences with real patients were relatively expensive (median > $1,000 per physician). Mailed paper materials, video clips, and audit and feedback performed by others were relatively inexpensive (median ≤ $62 per physician). Details regarding ingredient selection (10 of 62 studies), quantitation (10), and pricing (26) were reported infrequently. CONCLUSIONS Some ingredients, including time, are more important (i.e., contribute more to total costs) than others and should be prioritized in cost evaluations. Data on the relative costs of instructional modalities are insightful but limited. The methods and reporting of cost valuations merit improvement.
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Affiliation(s)
- David A Cook
- D.A. Cook is professor of medicine and medical education, director, Section of Research and Data Analytics, School of Continuous Professional Development, director of education science, Office of Applied Scholarship and Education Science, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, and consultant, Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota; ORCID: https://orcid.org/0000-0003-2383-4633
| | - John M Wilkinson
- J.M. Wilkinson is professor of family medicine, Mayo Clinic College of Medicine and Science, and consultant, Department of Family Medicine, Mayo Clinic, Rochester, Minnesota; ORCID: https://orcid.org/0000-0003-1156-8577
| | - Jonathan Foo
- J. Foo is a lecturer, Department of Physiotherapy, School of Primary and Allied Health Care, Monash University, Melbourne, Victoria, Australia; ORCID: https://orcid.org/0000-0003-4533-8307
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Falconer N, Paterson DL, Peel N, Welch A, Freeman C, Burkett E, Hubbard R, Comans T, Hanjani LS, Pascoe E, Hawley C, Gray L. A multimodal intervention to optimise antimicrobial use in residential aged care facilities (ENGAGEMENT): protocol for a stepped-wedge cluster randomised trial. Trials 2022; 23:427. [PMID: 35597993 PMCID: PMC9123829 DOI: 10.1186/s13063-022-06323-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 04/21/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Inappropriate antibiotic use can cause harm and promote antimicrobial resistance, which has been declared a major health challenge by the World Health Organization. In Australian residential aged care facilities (RACFs), the most common indications for antibiotic prescribing are for infections of the urinary tract, respiratory tract and skin and soft tissue. Studies indicate that a high proportion of these prescriptions are non-compliant with best prescribing guidelines. To date, a variety of interventions have been reported to address inappropriate prescribing and overuse of antibiotics but with mixed outcomes. This study aims to identify the impact of a set of sustainable, multimodal interventions in residential aged care targeting three common infection types. METHODS This protocol details a 20-month stepped-wedge cluster-randomised trial conducted across 18 RACFs (as 18 clusters). A multimodal multi-disciplinary set of interventions, the 'AMS ENGAGEMENT bundle', will be tailored to meet the identified needs of participating RACFs. The key elements of the intervention bundle include education for nurses and general practitioners, telehealth support and formation of an antimicrobial stewardship team in each facility. Prior to the randomised sequential introduction of the intervention, each site will act as its own control in relation to usual care processes for antibiotic use and stewardship. The primary outcome for this study will be antibiotic consumption measured using defined daily doses (DDDs). Cluster-level rates will be calculated using total occupied bed numbers within each RACF during the observation period as the denominator. Results will be expressed as rates per 1000 occupied bed days. An economic analysis will be conducted to compare the costs associated with the intervention to that of usual care. A comprehensive process evaluation will be conducted using the REAIM Framework, to enable learnings from the trial to inform sustainable improvements in this field. DISCUSSION A structured AMS model of care, incorporating targeted interventions to optimise antimicrobial use in the RACF setting, is urgently needed and will be delivered by our trial. The trial will aim to empower clinicians, residents and families by providing a robust AMS programme to improve antibiotic-related health outcomes. TRIAL REGISTRATION US National Library of Medicine Clinical Trials.gov ( NCT04705259 ). Prospectively registered in 12th of January 2021.
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Affiliation(s)
- Nazanin Falconer
- UQ Centre for Health Services Research, Faculty of Medicine, The University of Queensland, The University of Queensland, Brisbane, QLD, 4102, Australia.
- Department of Pharmacy, Princess Alexandra Hospital, Metro South Health, Brisbane, QLD, 4102, Australia.
- School of Pharmacy, Faculty of Health and Behavioural Sciences, The University of Queensland, The University of Queensland, Brisbane, QLD, 4102, Australia.
| | - David L Paterson
- UQ Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Royal Brisbane and Women's Hospital Campus, Brisbane, Australia
- Royal Brisbane and Women's Hospital, Metro North Health, Butterfield Street, Herston, Brisbane, QLD, 4029, Australia
| | - Nancye Peel
- UQ Centre for Health Services Research, Faculty of Medicine, The University of Queensland, The University of Queensland, Brisbane, QLD, 4102, Australia
| | - Alyssa Welch
- UQ Centre for Health Services Research, Faculty of Medicine, The University of Queensland, The University of Queensland, Brisbane, QLD, 4102, Australia
| | - Christopher Freeman
- School of Pharmacy, Faculty of Health and Behavioural Sciences, The University of Queensland, The University of Queensland, Brisbane, QLD, 4102, Australia
| | - Ellen Burkett
- Department of Emergency Medicine, Princess Alexandra Hospital, Woolloongabba, Brisbane, QLD, 4102, Australia
| | - Ruth Hubbard
- UQ Centre for Health Services Research, Faculty of Medicine, The University of Queensland, The University of Queensland, Brisbane, QLD, 4102, Australia
- Princess Alexandra Hospital Southside Clinical Unit, Faculty of Medicine, The University of Queensland, Woolloongabba, Brisbane, QLD, 4102, Australia
| | - Tracy Comans
- UQ Centre for Health Services Research, Faculty of Medicine, The University of Queensland, The University of Queensland, Brisbane, QLD, 4102, Australia
| | - Leila Shafiee Hanjani
- UQ Centre for Health Services Research, Faculty of Medicine, The University of Queensland, The University of Queensland, Brisbane, QLD, 4102, Australia
| | - Elaine Pascoe
- UQ Centre for Health Services Research, Faculty of Medicine, The University of Queensland, The University of Queensland, Brisbane, QLD, 4102, Australia
| | - Carmel Hawley
- UQ Centre for Health Services Research, Faculty of Medicine, The University of Queensland, The University of Queensland, Brisbane, QLD, 4102, Australia
- Princess Alexandra Hospital Southside Clinical Unit, Faculty of Medicine, The University of Queensland, Woolloongabba, Brisbane, QLD, 4102, Australia
| | - Leonard Gray
- UQ Centre for Health Services Research, Faculty of Medicine, The University of Queensland, The University of Queensland, Brisbane, QLD, 4102, Australia
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Zimmerman S, Resnick B, Ouslander J, Levy C, Gaugler JE, Sloane PD, Mor V. Pragmatic Trials and Improving Long-Term Care: Recommendations From a National Institutes of Health Conference. J Am Med Dir Assoc 2022; 23:323-327. [DOI: 10.1016/j.jamda.2022.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 01/06/2022] [Indexed: 12/27/2022]
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Zimmerman S, Resnick B, Ouslander J, Levy C, Gaugler JE, Sloane PD, Mor V. Pragmatic Trials and Improving Long-Term Care: Recommendations From a National Institutes of Health Conference. J Am Geriatr Soc 2022; 70:688-694. [PMID: 35195278 PMCID: PMC8915540 DOI: 10.1111/jgs.17697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 02/01/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Sheryl Zimmerman
- Cecil G. Sheps Center for Health Services Research and Schools of Social Work and Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA,Address correspondence to Sheryl Zimmerman, PhD, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, 725 Martin Luther King Jr Blvd, Campus Box 7590, Chapel Hill, NC 27599-7590, USA. (S. Zimmerman)
| | - Barbara Resnick
- University of Maryland School of Nursing, Baltimore, MD, USA
| | - Joseph Ouslander
- Department of Integrated Medical Sciences, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA
| | - Cari Levy
- Department of Veterans Affairs, Rocky Mountain Regional VA Medical Center, and University of Colorado, Aurora, CO, USA
| | - Joseph E. Gaugler
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Philip D. Sloane
- Cecil G. Sheps Center for Health Services Research and Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Vincent Mor
- Center of Innovation in Long-term Services and Supports, Providence VA Medical Center; Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA
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Zimmerman S, Resnick B, Ouslander J, Levy C, Gaugler JE, Sloane PD, Mor V. Pragmatic trials and improving long-term care: Recommendations from a national institutes of health conference. Geriatr Nurs 2022; 44:288-292. [DOI: 10.1016/j.gerinurse.2022.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Use of a Telemedicine Team to Improve Guideline-Based Antibiotic Prescribing. J Am Med Dir Assoc 2021; 23:1011-1018.e2. [PMID: 34688608 DOI: 10.1016/j.jamda.2021.09.031] [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: 06/17/2021] [Revised: 09/23/2021] [Accepted: 09/24/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVES Assessing the impact of a virtual antibiotic team (VAT) on appropriateness of antibiotic prescribing behavior of older care physicians, regarding urinary tract (UTI), respiratory tract (RTI), and skin and soft tissue infections (SSTI), in residents of long-term care facilities (LTCF). DESIGN Before-after trial; introduction of a VAT consisting of a clinical microbiologist, older care physician, and a pharmacist. SETTING AND PARTICIPANTS Eight LTCFs in Amsterdam, the Netherlands. METHODS The VAT was introduced on April 1, 2019. Meetings were held via weekly teleconferencing. VAT advised about treatment indication, antibiotic choice, and additional diagnostics. Data were retrospectively extracted from resident files regarding infection episodes for which antibiotics had been prescribed during 12 months before (period I) and 11 months after VAT introduction (period II). Appropriateness of antibiotic prescriptions was assessed using national guidelines and an algorithm developed for antimicrobial stewardship in nursing homes. Antibiotic prescription rates per 100 person-years (py) were estimated and compared between periods using incidence rate ratio (IRR) with 95% confidence intervals (CIs). Proportions of appropriate antibiotic prescriptions were compared between periods using the chi-squared test. RESULTS A total of 524 infection episodes for which antibiotics were prescribed were identified: 284 in period I and 240 in period II. Antibiotic prescription rates before VAT introduction were 73 per 100 py in period I and decreased to 68 in period II (IRR 0.9, 95% CI 0.8-1.1). Of all prescriptions, 23.9% were assessed as appropriate during period I, which increased to 40.4% in period II (P < .001). Appropriate antibiotic use increased after VAT introduction for RTI (12.5% to 48.2%, P < .001) and SSTI (47.5% to 74.3%, P = .02) but remained similar for UTI (23.5% to 28.8%, P = .29). CONCLUSIONS AND IMPLICATIONS After implementation of VAT in LTCFs, appropriate antibiotic use increased significantly overall, and for RTI and SSTI particularly. Improving prescribing behavior regarding UTI might need extra strategies.
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Lieb KM, Gowan T, Stump TE, Unroe KT, Sachs GA, Weiner M. Nursing Home Residents With Urinary Tract Infections: A Comparison of Treatment in Place vs Hospitalization. J Am Med Dir Assoc 2021; 22:2603-2605. [PMID: 34461044 DOI: 10.1016/j.jamda.2021.07.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 05/03/2021] [Accepted: 07/27/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Kristi M Lieb
- Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Tayler Gowan
- Regenstrief Institute, Inc, Indianapolis, IN, USA
| | - Timothy E Stump
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kathleen T Unroe
- Indiana University School of Medicine, Indianapolis, IN, USA; Regenstrief Institute, Inc, Indianapolis, IN, USA
| | - Greg A Sachs
- Indiana University School of Medicine, Indianapolis, IN, USA; Regenstrief Institute, Inc, Indianapolis, IN, USA
| | - Michael Weiner
- Indiana University School of Medicine, Indianapolis, IN, USA; Regenstrief Institute, Inc, Indianapolis, IN, USA; Center for Health Information and Communication, US Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service CIN 13-416, Richard L. Roudebush VA Medical Center, Indianapolis, IN
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Raban MZ, Gates PJ, Gasparini C, Westbrook JI. Temporal and regional trends of antibiotic use in long-term aged care facilities across 39 countries, 1985-2019: Systematic review and meta-analysis. PLoS One 2021; 16:e0256501. [PMID: 34424939 PMCID: PMC8382177 DOI: 10.1371/journal.pone.0256501] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 08/08/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Antibiotic misuse is a key contributor to antimicrobial resistance and a concern in long-term aged care facilities (LTCFs). Our objectives were to: i) summarise key indicators of systemic antibiotic use and appropriateness of use, and ii) examine temporal and regional variations in antibiotic use, in LTCFs (PROSPERO registration CRD42018107125). METHODS & FINDINGS Medline and EMBASE were searched for studies published between 1990-2021 reporting antibiotic use rates in LTCFs. Random effects meta-analysis provided pooled estimates of antibiotic use rates (percentage of residents on an antibiotic on a single day [point prevalence] and over 12 months [period prevalence]; percentage of appropriate prescriptions). Meta-regression examined associations between antibiotic use, year of measurement and region. A total of 90 articles representing 78 studies from 39 countries with data between 1985-2019 were included. Pooled estimates of point prevalence and 12-month period prevalence were 5.2% (95% CI: 3.3-7.9; n = 523,171) and 62.0% (95% CI: 54.0-69.3; n = 946,127), respectively. Point prevalence varied significantly between regions (Q = 224.1, df = 7, p<0.001), and ranged from 2.4% (95% CI: 1.9-2.7) in Eastern Europe to 9.0% in the British Isles (95% CI: 7.6-10.5) and Northern Europe (95% CI: 7.7-10.5). Twelve-month period prevalence varied significantly between regions (Q = 15.1, df = 3, p = 0.002) and ranged from 53.9% (95% CI: 48.3-59.4) in the British Isles to 68.3% (95% CI: 63.6-72.7) in Australia. Meta-regression found no association between year of measurement and antibiotic use prevalence. The pooled estimate of the percentage of appropriate antibiotic prescriptions was 28.5% (95% CI: 10.3-58.0; n = 17,245) as assessed by the McGeer criteria. Year of measurement was associated with decreasing appropriateness of antibiotic use over time (OR:0.78, 95% CI: 0.67-0.91). The most frequently used antibiotic classes were penicillins (n = 44 studies), cephalosporins (n = 36), sulphonamides/trimethoprim (n = 31), and quinolones (n = 28). CONCLUSIONS Coordinated efforts focusing on LTCFs are required to address antibiotic misuse in LTCFs. Our analysis provides overall baseline and regional estimates for future monitoring of antibiotic use in LTCFs.
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Affiliation(s)
- Magdalena Z. Raban
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Peter J. Gates
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Claudia Gasparini
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Johanna I. Westbrook
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
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Are antimicrobial stewardship interventions effective and safe in long-term care facilities? A systematic review and meta-analysis. Clin Microbiol Infect 2021; 27:1431-1438. [PMID: 34118423 DOI: 10.1016/j.cmi.2021.06.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 05/14/2021] [Accepted: 06/01/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Long-term care facilities (LTCFs) are health-care settings with high antimicrobial consumption and hence need to develop effective antimicrobial stewardship programmes (ASPs). OBJECTIVE To assess the effects of ASPs on care-related, clinical and ecological outcomes in LTCFs. METHODS Data sources were PubMed, EMBASE, CINAHL and SCOPUS. Study eligibility criteria were original research articles (controlled clinical trials or controlled before and after studies) published up to 1 October 2020. Participants were adult residents of LTCFs, residential aged-care facilities, nursing homes, veterans' homes, skilled nursing facilities and assisted living facilities for older people. Interventions included ASPs versus standard care. Outcomes assessed were antimicrobial consumption and appropriateness, infections, hospital admissions and mortality. Available data were pooled in a meta-analysis, and inconsistency between studies was evaluated using the I2 statistic. Certainty of evidence was assessed using the GRADE approach. RESULTS Of the 3111 papers identified, 12 studies met the inclusion criteria. All of them analysed the impact of interventions on antimicrobial use based on consumption-related variables (n = 8) and/or percentage of inappropriate prescriptions (n = 6). Pooled data showed a mean difference of -0.47 prescriptions per 1000 resident-days in favour of ASPs (95% CI -0.87 to -0.07, I2 = 71%). Five studies analysed the clinical effect of ASPs on the number of hospital admissions and/or resident mortality. The meta-analysis showed a mean difference of 0.17 hospital admissions per 1000 resident-days (95% CI -0.07 to 0.41, I2 = 17%) and a mean difference of -0.02 deaths per 1000 resident-days (95% CI -0.14 to 0.09, I2 = 0%). Only two studies included infections as a study outcome. CONCLUSIONS ASPs appear to improve antimicrobial use in this setting without increasing hospital admissions or deaths, indicating that these programmes do not lead to under-treatment of infections. Nonetheless, further higher-quality clinical trials are required to understand the effects of ASPs in LTCFs. PROSPERO REGISTRATION NUMBER CRD42021225127.
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Aliyu S, Travers JL, Heimlich SL, Ifill J, Smaldone A. Antimicrobial Stewardship Interventions to Optimize Treatment of Infections in Nursing Home Residents: A Systematic Review and Meta-Analysis. J Appl Gerontol 2021; 41:892-901. [PMID: 34075829 DOI: 10.1177/07334648211018299] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Effects of antibiotic stewardship program (ASP) interventions to optimize antibiotic use for infections in nursing home (NH) residents remain unclear. The aim of this systematic review and meta-analysis was to assess ASPs in NHs and their effects on antibiotic use, multi-drug-resistant organisms, antibiotic prescribing practices, and resident mortality. Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we conducted a systematic review and meta-analysis using five databases (1988-2020). Nineteen articles were included, 10 met the criteria for quantitative synthesis. Inappropriate antibiotic use decreased following ASP intervention in eight studies with a pooled decrease of 13.8% (95% confidence interval [CI]: [4.7, 23.0]; Cochran's Q = 166,837.8, p < .001, I2 = 99.9%) across studies. Decrease in inappropriate antibiotic use was highest in studies that examined antibiotic use for urinary tract infection (UTI). Education and antibiotic stewardship algorithms for UTI were the most effective interventions. Evidence surrounding ASPs in NH is weak, with recommendations suited for UTIs.
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Affiliation(s)
| | - Jasmine L Travers
- New York University Rory Meyers College of Nursing, New York City, USA
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Implementation of core elements of antibiotic stewardship in nursing homes-National Healthcare Safety Network, 2016-2018. Infect Control Hosp Epidemiol 2021; 43:752-756. [PMID: 34036926 DOI: 10.1017/ice.2021.209] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To assess the national uptake of the Centers for Disease Control and Prevention's (CDC) core elements of antibiotic stewardship in nursing homes from 2016 to 2018 and the effect of infection prevention and control (IPC) hours on the implementation of the core elements. DESIGN Retrospective, repeated cross-sectional analysis. SETTING US nursing homes. METHODS We used the National Healthcare Safety Network (NHSN) Long-Term Care Facility Component annual surveys from 2016 to 2018 to assess nursing home characteristics and percent implementation of the core elements. We used log-binomial regression models to estimate the association between weekly IPC hours and the implementation of all 7 core elements while controlling for confounding by facility characteristics. RESULTS We included 7,506 surveys from 2016 to 2018. In 2018, 71% of nursing homes reported implementation of all 7 core elements, a 28% increase from 2016. The greatest increases in implementation from 2016 to 2018 were in education (19%), reporting (18%), and drug expertise (15%). In 2018, 71% of nursing homes reported pharmacist involvement in improving antibiotic use, an increase of 27% since 2016. Nursing homes that reported at least 20 hours of IPC activity per week were 14% (95% confidence interval, 7%-20%) more likely to implement all 7 core elements when controlling for facility ownership and affiliation. CONCLUSIONS Nursing homes reported substantial progress in antibiotic stewardship implementation from 2016 to 2018. Improvements in access to drug expertise, education, and reporting antibiotic use may reflect increased stewardship awareness and resource use among nursing home providers under new regulatory requirements. Nursing home stewardship programs may benefit from increased IPC staff hours.
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Felsen CB, Dodds Ashley ES, Barney GR, Nelson DL, Nicholas JA, Yang H, Aydelotte ME, Karlic A, Nicholas NC, Petrone KK, Pine RD, Schabel SL, Medina-Walpole A, Dumyati GK. Reducing Fluoroquinolone Use and Clostridioides difficile Infections in Community Nursing Homes Through Hospital-Nursing Home Collaboration. J Am Med Dir Assoc 2021; 21:55-61.e2. [PMID: 31888865 DOI: 10.1016/j.jamda.2019.11.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Revised: 11/12/2019] [Accepted: 11/12/2019] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Nursing homes (NHs) are an important target for antibiotic stewardship (AS). We describe a collaborative model to reduce Clostridioides difficile infections (CDIs) in NHs through optimization of antibiotic use including a reduction in high-risk antibiotics such as fluoroquinolones. DESIGN Quasi-experimental, pre- and post-intervention study. SETTING AND PARTICIPANTS Six NHs in Monroe County, NY. METHODS A hospital-based AS expert team assisted NHs in identifying targets for improving antibiotic use. Interventions included (1) collaboration with a medical director advisory group to develop NH consensus guidelines for testing and treatment of 2 syndromes (urinary tract infections and pneumonia) for which fluoroquinolone use is common, (2) provision of multifaceted NH staff education on these guidelines and education of residents and family members on the judicious use of antibiotics, and (3) sharing facility-specific and comparative antibiotic and CDI data. We used Poisson regression to estimate antibiotic use per 1000 resident days (RD) and CDIs per 10,000 RD, pre- and post-intervention. Segmented regression analysis was used to estimate changes in fluoroquinolone and total antibiotic rates over time. RESULTS Postintervention, the monthly rate of fluoroquinolone days of therapy (DOT) per 1000 RD significantly decreased by 39% [rate ratio (RR) 0.61, 95% confidence interval (CI) 0.59-0.62, P < .001] across all NHs and the total antibiotic DOT decreased by 9% (RR 0.91, 95% CI 0.90-0.92, P < .001). Interrupted time series analysis of fluoroquinolone and total DOT rates confirmed these changes. The quarterly CDI rate decreased by 18% (RR 0.82, 95% CI 0.68-0.99, P = .042). CONCLUSIONS AND IMPLICATIONS A hospital-NH partnership with a medical director advisory group achieved a significant reduction in total antibiotic and fluoroquinolone use and contributed to a reduction in CDI incidence. This approach offers one way for NHs to gain access to AS expertise and resources and to standardize practices within the local community.
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Affiliation(s)
- Christina B Felsen
- Center for Community Health and Prevention, University of Rochester Medical Center, Rochester, NY
| | - Elizabeth S Dodds Ashley
- Division of Infectious Diseases and International Health, Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, NC
| | - Grant R Barney
- Emerging Infections Program, New York State Department of Health, Albany, NY
| | - Dallas L Nelson
- Department of Medicine, Geriatrics/Aging University of Rochester Medical Center, Rochester, NY
| | - Joseph A Nicholas
- Department of Medicine and Physical Medicine and Rehabilitation, University of Rochester Medical Center, Rochester, NY
| | - Hongmei Yang
- Department of Biostatistics and Computational Biology, University of Rochester Medical Center, Rochester, NY
| | | | - Alexander Karlic
- Unity Living Center and Unity Hospital, Rochester Regional Health, Rochester, NY
| | - Nirmala C Nicholas
- Department of Medicine, Geriatrics/Aging University of Rochester Medical Center, Rochester, NY
| | | | | | - Scott L Schabel
- Division of Long Term Care, Rochester Regional Health, Rochester, NY
| | - Annette Medina-Walpole
- Department of Medicine, Geriatrics/Aging University of Rochester Medical Center, Rochester, NY
| | - Ghinwa K Dumyati
- Center for Community Health and Prevention, University of Rochester Medical Center, Rochester, NY; Department of Medicine, Division of Infectious Disease, University of Rochester Medical Center, Rochester, NY.
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Heudorf U, Berres M, Schmehl C, Steul K. Antibiotic consumption surveillance in rehabilitation facilities - a new task according to § 23 of the German Infection Protection Act. Data from rehabilitation facilities in the Rhine-Main area, 2016-2018. GMS HYGIENE AND INFECTION CONTROL 2020; 15:Doc30. [PMID: 33299743 PMCID: PMC7709149 DOI: 10.3205/dgkh000365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Background: Multidrug-resistant pathogens are a major health problem in many countries. In Germany, in accordance with the German Antibiotic Resistance Strategy (DART), the surveillance of antibiotic consumption in acute care hospitals and rehabilitation facilities was made mandatory by the Infection Protection Act in 2011 and 2017. Whereas comparable reference data for acute care hospitals are available, such data is lacking for rehabilitation facilities. Therefore, the Rhine-Main network on MDRO (Multi Drug Resistant Organisms) has offered to evaluate the antibiotic consumption of the network's rehabilitation facilities. Antimicrobial consumption (if possible already given as daily defined doses, DDD) and patient days from 2016-2018 were requested. Materials and methods: By October 31, 2019, nine clinics, including a facility for early neurological rehabilitation, reported their consumption of antibiotics (mostly already as DDD) and patient days from 2016-2018. The information from the clinics was entered in an Excel table and the DDD calculated if necessary. In order to compare the facilities, the DDD/100 patient days (pd) were calculated for the individual active substances. Results: Antibiotic consumption in general rehabilitation facilities decreased slightly from 4.8 DDD/100 pd to 4.4 DDD/100 pd from 2016 to 2018. In early neurological rehabilitation, antibiotic consumption increased from 10.2 DDD/100 pd to 13.1 DDD/100 pd in the same period. Among the most commonly used antibiotics, cefuroxime came first, followed by ciprofloxacin and amoxicillin in third place. Discussion: To our knowledge, this is the first antimicrobial consumption data from rehabilitation facilities in Germany. Antibiotic consumption in general rehabilitation facilities is less than 10% of the consumption in normal/regular wards of acute care clinics, and the consumption in neurological early rehabilitation was approximately 10% of the consumption in intensive care wards within acute care clinics. Reserve or broad-spectrum antibiotics were rarely or not used at all in the rehabilitation facilities. Despite this overall positive situation, antibiotic stewardship should also be introduced in rehabilitation facilities, possibly with the support of the regional MDRO networks.
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Affiliation(s)
- Ursel Heudorf
- MDRO Network Rhine-Main, Frankfurt am Main, Germany,*To whom correspondence should be addressed: Ursel Heudorf, MDRO Network Rhine-Main, Breite Gasse 28, 60313 Frankfurt am Main, Germany, Phone: 0049 6921248884, E-mail:
| | | | - Cleo Schmehl
- MDRO Network Rhine-Main, Frankfurt am Main, Germany
| | - Katrin Steul
- MDRO Network Rhine-Main, Frankfurt am Main, Germany
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"There is no one to pick up the pieces": Sustainability of antibiotic stewardship programs in nursing homes. Infect Control Hosp Epidemiol 2020; 42:440-447. [PMID: 33100251 DOI: 10.1017/ice.2020.1217] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To describe nursing home staff experiences and perceptions of the factors that impact the sustainability of an antibiotic stewardship program (ASP). METHODS Using a qualitative descriptive design, semistructured interviews with staff at 9 not-for-profit nursing homes with an established ASP were conducted and audio recorded. De-identified transcriptions of the interviews were coded using a sustainability framework and were analyzed to identify themes. RESULTS Interviews were conducted with 48 clinical and administrative staff to elicit their perceptions of the ASPs, and 7 themes were identified. ASPs were perceived to be resource intensive and "data driven," requiring access to and interpretation of data that are not readily available at many nursing homes. Though motivated and committed, ASP champions felt that they could not single-handedly sustain the program. Attending to daily clinical needs (ie, "fires") made it hard to progress beyond implementation and to reach step 2 of sustainability. Longstanding treatment habits by external prescribers and regulations were believed to impede ASP efforts. Partnerships with an external consultant with antibiotic stewardship expertise were considered important, as was the need for internal leadership support and collaboration across disciplinary boundaries. Participants felt that consistent and ongoing education on antibiotic stewardship at all staff levels was important. CONCLUSIONS Although many interconnected factors impact the sustainability of an ASP, nursing homes may be able to sustain an ASP by focusing on 3 critical areas: (1) explicit support by nursing home leadership, (2) external partnerships with professionals with antibiotic stewardship expertise and internal interprofessional collaborations, and (3) consistent education and training for all staff.
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Improvements in Antibiotic Appropriateness for Cystitis in Older Nursing Home Residents: A Quality Improvement Study With Randomized Assignment. J Am Med Dir Assoc 2020; 22:173-177. [PMID: 32948472 DOI: 10.1016/j.jamda.2020.07.040] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 07/22/2020] [Accepted: 07/24/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To determine the impact of an educational quality improvement initiative on the appropriateness of antibiotic prescribing restricted to uncomplicated cystitis in older noncatheterized nursing home residents. DESIGN Quality improvement study with randomized assignment. SETTINGS AND PARTICIPANTS Twenty-five nursing homes in United States were randomized to the intervention or usual care group by strata that included state, urban/rural status, bed size, and geographic separation. METHODS A 12-month trial of a low-intensity multifaceted antimicrobial stewardship intervention focused on uncomplicated cystitis in nursing home residents vs usual care. The outcome was the modified Medication Appropriateness Index as assessed by a blinded geriatric clinical pharmacist and consisted of an assessment of antibiotic effectiveness, dosage, drug-drug interactions, and duration. RESULTS There were 75 cases (0.15/1000 resident days) in intervention and 92 (0.22/1000 resident days) in control groups with a probable cystitis per consensus guidelines. Compared with controls, there was a statistically nonsignificant 21% reduction in the risk of inappropriate antibiotic prescribing (nonzero Medication Appropriateness Index score rate 0.13 vs 0.21/1000 person days; adjusted incident rate ratio 0.79; 95% confidence interval 0.45‒1.38). There was a favorable comparison in inappropriateness of duration (77% vs 89% for intervention vs control groups, respectively; P = .0394). However, the intervention group had more problems with drug-drug interactions than the control group (8% vs 1%, respectively; P = .0463). Similarly, the intervention group had a nonsignificant trend toward more problems with dosage (primarily because of the lack of adjustment for decreased renal function) than the control group (32% vs 25%, respectively; P = .3170). Both groups had similar rates of problems with choice/effectiveness (44% vs 45%; P = .9417). The most common class of antibiotics prescribed inappropriately was quinolones (25% vs 23% for intervention versus control groups, respectively; P = .7057). CONCLUSIONS AND IMPLICATIONS A low-intensity intervention showed a trend toward improved appropriate antibiotic prescribing in nursing home residents with likely uncomplicated cystitis. Efforts to improve antibiotic prescribing in addition to the low-intensity intervention might include a consultant pharmacist in a nursing home to identify inappropriate prescribing practices.
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Oliveira I, Rego C, Semedo G, Gomes D, Figueiras A, Roque F, Herdeiro MT. Systematic Review on the Impact of Guidelines Adherence on Antibiotic Prescription in Respiratory Infections. Antibiotics (Basel) 2020; 9:E546. [PMID: 32867122 PMCID: PMC7557871 DOI: 10.3390/antibiotics9090546] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 08/21/2020] [Accepted: 08/25/2020] [Indexed: 11/26/2022] Open
Abstract
Overuse and inappropriate antibiotic prescription for respiratory tract infections (RTI) are one of the major contributors to the current antibiotic resistance problem. Guidelines provide support to prescribers for proper decision-making. Our purpose is to review the impact of prescribers' exposure to guidelines in antibiotic prescription for RTIs. A systematic review was performed searching in the scientific databases MEDLINE PubMed and EMBASE for studies which exposed prescribers to guidelines for RTI and compared antibiotic prescription rates/quality before and after the implementation, with thirty-four articles included in the review. The selected studies consisted on a simple intervention in the form of guideline implementation while others involved multifaceted interventions, and varied in population, designs, and settings. Prescription rate was shown to be reduced in the majority of the studies, along with an improvement in appropriateness, defined mainly by the prescription of narrow-spectrum rather than broad-spectrum antibiotics. Intending to ascertain if this implementation could decrease prescription costs, 7 articles accessed it, of which 6 showed the intended reduction. Overall interventions to improve guidelines adherence can be effective in reducing antibiotic prescriptions and inappropriate antibiotic selection for RTIs, supporting the importance of implementing guidelines in order to decrease the high levels of antibiotic prescriptions, and consequently reduce antimicrobial resistance.
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Affiliation(s)
- Inês Oliveira
- Faculty of Health, Medicine and Life Sciences, University of Maastricht, 6200 MD Maastricht, The Netherlands;
| | - Catarina Rego
- Faculty of Pharmacy of the University of Lisbon, 1649 Lisbon, Portugal;
| | - Guilherme Semedo
- Department of Medical Sciences, University of Aveiro, 3810 Aveiro, Portugal;
| | - Daniel Gomes
- Research Unit for Inland Development, Polytechnic of Guarda (UDI-IPG), 6300 Guarda, Portugal;
| | - Adolfo Figueiras
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, 15702 Santiago de Compostela, Spain;
- Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain
- Consortium for Biomedical Research in Epidemiology & Public Health (CIBERESP), 28001 Madrid, Spain
| | - Fátima Roque
- Research Unit for Inland Development, Polytechnic of Guarda (UDI-IPG), 6300 Guarda, Portugal;
- Health Sciences Research Centre, University of Beira Interior (CICS-UBI), 6200 Covilhã, Portugal
| | - Maria Teresa Herdeiro
- Department of Medical Sciences, Institute of Biomedicine–iBiMED, University of Aveiro, 3810 Aveiro, Portugal;
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Sloane PD. Cruise Ships, Nursing Homes, and Prisons as COVID-19 Epicenters: A "Wicked Problem" With Breakthrough Solutions? J Am Med Dir Assoc 2020; 21:958-961. [PMID: 32674828 PMCID: PMC7190531 DOI: 10.1016/j.jamda.2020.04.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 04/23/2020] [Indexed: 12/25/2022]
Affiliation(s)
- Philip D Sloane
- Cecil G. Sheps Center for Health Services Research and Departments of Family Medicine and Internal Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC.
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25
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Furuno JP, Mody L. Several Roads Lead to Rome: Operationalizing Antibiotic Stewardship Programs in Nursing Homes. J Am Geriatr Soc 2019; 68:11-14. [PMID: 31825520 DOI: 10.1111/jgs.16279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 11/08/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Jon P Furuno
- Department of Pharmacy Practice, Oregon State University College of Pharmacy, Portland, Oregon
| | - Lona Mody
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Detroit, Michigan.,Geriatrics Research Education and Clinical Center, Veterans Affairs Ann Arbor Healthcare System, Detroit, Michigan
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Antimicrobial resistance patterns of urine culture specimens from 27 nursing homes: Impact of a two-year antimicrobial stewardship intervention. Infect Control Hosp Epidemiol 2019; 40:780-786. [DOI: 10.1017/ice.2019.108] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
AbstractObjective:Identify changes in the prevalence and antimicrobial resistance patterns of potentially pathogenic bacteria in urine cultures during a 2-year antimicrobial stewardship intervention program in nursing homes (NHs).Design:Before-and-after intervention study.Setting:The study included 27 NHs in North Carolina.Methods:We audited all urine cultures ordered before and during an antimicrobial stewardship intervention. Analyses compared culture rates, culture positive rates, and pathogen antimicrobial resistance patterns.Results:Of 6,718 total urine cultures collected, 68% were positive for potentially pathogenic bacteria. During the intervention, significant reductions in the urine culture and positive culture rates were observed (P= .014). Most of the identified potentially uropathogenic isolates wereEscherichia coli(38%),Proteusspp (13%), andKlebsiella pneumoniae(12%). A significant decrease was observed during the intervention period in nitrofurantoin resistance amongE. coli(P≤ .001) and ciprofloxacin resistance amongProteusspp (P≤ .001); however carbapenem resistance increased forProteusspp (P≤ .001). Multidrug resistance also increased forProteusspp compared to the baseline. The high baseline resistance ofE. colito the commonly prescribed antimicrobials ciprofloxacin and trimethoprim-sulfamethoxazole (TMP/SMX) did not change during the intervention.Conclusions:The antimicrobial stewardship intervention program significantly reduced urine culture and culture-positive rates. Overall, very high proportions of antimicrobial resistance were observed among common pathogens; however, antimicrobial resistance trended downward but reductions were too small and scattered to conclude that the intervention significantly changed antimicrobial resistance. Longer intervention periods may be needed to effect change in resistance patterns.
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