Antibiotics for acute respiratory tract infections: a mixed-methods study of patient experiences of non-medical prescriber management

Understanding patient demand for and use of antibiotics for upper respiratory tract infection: A qualitative application of the Necessity-Concerns Framework in Saudi Arabia

Background

Reducing antimicrobial resistance (AMR) is a priority for public health. Inappropriate patient demand is an important driver of unnecessary antibiotic use. To develop an effective intervention to reduce inappropriate demand for antibiotics in upper respiratory tract infections (URTIs), it is important to identify patient perceptions that influence demand for, and appropriate use of antibiotics.

Aim

To identify and describe the beliefs about antibiotics necessity and concerns that patients with URTIs have, in Riyadh, Saudi Arabia.

Method

An exploratory qualitative approach was used. One-to-one, face-to-face or telephone semi-structured interviews were conducted with participants recruited using purposive sampling (based on age and gender) from primary healthcare centre in Riyadh, Saudi Arabia were conducted. Only adult patients who currently experience URTIs symptoms and agreed to participate were recruited. Recruitment for interviews continued until data saturation point was reached. The interview guide explored patients' necessity beliefs and concerns about antibiotics, AMR perceptions, and expectations from URTIs consultation. Interview transcripts were coded using QSR NVivo 12 using framework analysis informed by the Necessity-Concerns Framework to identify key motivations driving antibiotic requests and consultations.

Results

the study interviewed 32 participants (44% were male, average age was 36.84). Results identified that the patients often relate their personal need for antibiotics when encountering an URTIs symptoms to the type, severity and duration of symptoms. Patients also linked antibiotics with quicker recovery, generally expressing few concerns about antibiotics mainly because of its short duration of use. However, some conveyed their concern about frequent administration of antibiotics and effect on the body's immune system function, which may make them more prone to infections in the future. Participants varied widely in their awareness of AMR; this was associated with many misconceptions, such as confusing AMR with antibiotics efficacy and tolerance. Interestingly, the interplay between necessity beliefs and concerns was observed to influence the decision to start and stop antibiotic, potentially impacting inappropriate antibiotic demand and unnecessary use.

Conclusion

This study highlighted important beliefs and misconceptions about antibiotics and AMR in Saudi population which can be targeted in future interventions to reduce inappropriate demand for antibiotics and optimise appropriate usage.

Coping with in-locus factors and systemic contradictions affecting antibiotic prescription and dispensing practices in primary care-A qualitative One Health study in Brazil

Antimicrobial resistance (AMR) is an increasing threat to global health. The risks and sanitary consequences of AMR are disproportionately experienced by those living in Low- and Middle-Income Countries (LMICs). While addressing antibiotic use has largely been documented in hospital settings, the understanding of social drivers affecting antibiotic prescribing and dispensing practices in the context of human and animal health in primary care (PC) in LMICs remains extremely limited. We seek to explore how in-locus and multi-level social factors influence antibiotic prescriptions and dispensing practices in the context of human and animal health in primary care in Brazil. This is a baseline qualitative One Health study; semi-structured interviews and field observations were undertaken in primary care sites located in a socioeconomically vulnerable area in the city of São Paulo, the most populated city of Brazil. Twenty-five human and animal healthcare professionals (HP) were purposely sampled. Interview data were subject to thematic analysis. Three overlapping social drivers were identified across HPs' discourses: individual and behavioral challenges; relational and contextual factors influencing the overprescription of antibiotics (AB); and structural barriers and systemic contradictions in the health system. As a result of the interaction between multilevel in-locus and structural and contextual factors, HPs experience contextual and territorial challenges that directly influence their risk perception, diagnosis, use of laboratorial and image exams, time and decision to undergo treatment, choice of AB and strategies in coping with AB prescriptions. Additionally, in-locus factors influencing antibiotic prescriptions and dispensing practices are intertwined with individual accounts of risk management, systemic contradictions and ambivalences in the national health system. Our findings suggest interventions tackling AB use and AMR in Brazil should consider the social context, the complex health system structure and current integrated programs and services in PC.

Immunity-enhancing Micronutrients and Community Pharmacists: An Opportunity to Expand Self-Care Practices among the Public

Background: The urban lifestyle and environment pose a constant immune challenge to city dwellers. A major such challenge is influenza, which creates substantial public health and socio-economic burdens. The global healthcare paradigm has begun emphasizing the importance and cost-effectiveness of self-care in partnership with healthcare professionals such as community pharmacists for the management of mild ailments. For the general public, micronutrient supplementation is an affordable and potentially feasible self-care strategy for immunity enhancement and disease management. At the same time, micronutrient deficiencies are a serious public health concern in both developing and developed areas. Objective: This review focuses on the clinical evidence for the efficacy and safety of three key micronutrients — vitamins C, D and zinc — on respiratory infections. Key findings: These micronutrients are important for optimal immune function through their complementary roles in supporting both innate and adaptive immunity, as well as epithelial barriers. The need to improve public awareness of self-care in prevention and health management is highlighted by recent public health issues and the global fight against antimicrobial resistance. Community pharmacists could play a crucial role in empowering patient autonomy. Conclusion: With this review we aim to offer insights into the supplementation of these micronutrients as a self-care approach to the management of immune health.

Barriers and facilitators to implementation of non-medical independent prescribing in primary care in the UK: a qualitative systematic review

OBJECTIVES

To support workforce deficits and rising demand for medicines, independent prescribing (IP) by nurses, pharmacists and allied health professionals is a key component of workforce transformation in UK healthcare. This systematic review of qualitative research studies used a thematic synthesis approach to explore stakeholders' views on IP in primary care and identify barriers and facilitators influencing implementation.

SETTING

UK primary/community care.

PARTICIPANTS

Inclusion criteria were UK qualitative studies of any design, published in the English language. Six electronic databases were searched between January 2010 and September 2021, supplemented by reference list searching. Papers were screened, selected and quality-appraised using the Quality Assessment Tool for Studies with Diverse Designs. Study data were extracted to a bespoke table and two reviewers used NVivo software to code study findings. An inductive thematic synthesis was undertaken to identify descriptive themes and interpret these into higher order analytical themes. The Diffusion of Innovations and Consolidated Framework for Implementation Research were guiding theoretical anchors.

PRIMARY AND SECONDARY OUTCOME MEASURES

N/A.

RESULTS

Twenty-three articles addressing nurse, pharmacist and physiotherapist IP were included. Synthesis identified barriers and facilitators in four key stages of implementation: (1) 'Preparation', (2) 'Training', (3) 'Transition' and 4) 'Sustainment'. Enhancement, substitution and role-specific implementation models reflected three main ways that the IP role was used in primary care.

CONCLUSIONS

In order to address global deficits, there is increasing need to optimise use of IP capability. Although the number of independent prescribers continues to grow, numerous barriers to implementation persist. A more coordinated and targeted approach is key to overcoming barriers identified in the four stages of implementation and would help ensure that IP is recognised as an effective approach to help alleviate workforce shortfalls in the UK, and around the world.

PROSPERO REGISTRATION NUMBER

CRD42019124400.

Medicines prescribed by non-medical independent prescribers in primary care in Wales: a 10-year longitudinal study April 2011-March 2021

OBJECTIVES

The therapeutic classes of medicines prescribed by non-medical independent prescribers (NMIPs) working in primary care in Wales has not been studied in detail. The aim of this study was to conduct a 10-year longitudinal analysis of NMIP prescribing in Wales from April 2011 to March 2021. The study examined the British National Formulary (BNF) chapters from which medicines were prescribed by NMIPs, whether this changed over time, and whether there was variation in prescribing across the geographic regions of Wales.

DESIGN

Retrospective secondary data analysis of primary care prescribing data. Monthly prescribing data for the 10 National Health Service financial years (April to March) from April 2011 to March 2021 were obtained from the Comparative Analysis System for Prescribing Audit software. Data were analysed according to BNF chapter, to identify in which therapeutic areas NMIPs were prescribing, and whether this changed over the study period.

RESULTS

The number of items prescribed by NMIPs increased during the study period. From April 2011 to March 2021 prescribing in seven BNF chapters equated to approximately 80% of total items, with cardiovascular system medicines most prescribed. In the financial year 2011-2012 the BNF chapters with the greatest proportion of items prescribed were infection (18%) and respiratory system (13%), while in 2020-2021, these had changed to cardiovascular (23%) and nervous system (19%). The number of items prescribed in each health board in Wales varied, however, the BNF chapters contributing the largest percentages of items to the health board totals were broadly comparable.

CONCLUSIONS

The BNF chapter with the most prescribed items changed from infection to cardiovascular during the study period, suggesting an increase in chronic disease management by NMIPs. The impact of this on the delivery of primary care services and patient outcomes is a focus for future work.

Influences on antibiotic prescribing by non-medical prescribers for respiratory tract infections: a systematic review using the theoretical domains framework

BACKGROUND

The need to conserve antibiotic efficacy, through the management of respiratory tract infections (RTIs) without recourse to antibiotics, is a global priority. A key target for interventions is the antibiotic prescribing behaviour of healthcare professionals including non-medical prescribers (NMPs: nurses, pharmacists, paramedics, physiotherapists) who manage these infections.

OBJECTIVES

To identify what evidence exists regarding the influences on NMPs' antimicrobial prescribing behaviour and analyse the operationalization of the identified drivers of behaviour using the Theoretical Domains Framework (TDF).

METHODS

The search strategy was applied across six electronic bibliographic databases (eligibility criteria included: original studies; written in English and published before July 2019; non-medical prescribers as participants; and looked at influences on prescribing patterns of antibiotics for RTIs). Study characteristics, influences on appropriate antibiotic prescribing and intervention content to enhance appropriate antibiotic prescribing were independently extracted and mapped to the TDF.

RESULTS

The search retrieved 490 original articles. Eight papers met the review criteria. Key issues centred around strategies for managing challenges experienced during consultations, managing patient concerns, peer support and wider public awareness of antimicrobial resistance. The two most common TDF domains highlighted as influences on prescribing behaviour, represented in all studies, were social influences and beliefs about consequences.

CONCLUSIONS

The core domains highlighted as influential to appropriate antibiotic prescribing should be considered when developing future interventions. Focus should be given to overcoming social influences (patients, other clinicians) and reassurance in relation to beliefs about negative consequences (missing something that could lead to a negative outcome).

The use of theory in the development and evaluation of behaviour change interventions to improve antimicrobial prescribing: a systematic review

OBJECTIVES

This systematic review (SR) reviews the evidence on use of theory in developing and evaluating behaviour change interventions (BCIs) to improve clinicians' antimicrobial prescribing (AP).

METHODS

The SR protocol was registered with PROSPERO. Eleven databases were searched from inception to October 2018 for peer-reviewed, English-language, primary literature in any healthcare setting and for any medical condition. This included research on changing behavioural intentions (e.g. in simulated scenarios) and research measuring actual AP. All study designs/methodologies were included. Excluded were: grey literature and/or those which did not state a theory. Two reviewers independently extracted and quality assessed the data. The Theory Coding Scheme (TCS) evaluated the extent of the use of theory.

RESULTS

Searches found 4227 potentially relevant papers after removal of duplicates. Screening of titles/abstracts led to dual assessment of 38 full-text papers. Ten (five quantitative, three qualitative and two mixed-methods) met the inclusion criteria. Studies were conducted in the UK (n = 8), Canada (n = 1) and Sweden (n = 1), most in primary care settings (n = 9), targeting respiratory tract infections (n = 8), and medical doctors (n = 10). The most common theories used were Theory of Planned Behaviour (n = 7), Social Cognitive Theory (n = 5) and Operant Learning Theory (n = 5). The use of theory to inform the design and choice of intervention varied, with no optimal use as recommended in the TCS.

CONCLUSIONS

This SR is the first to investigate theoretically based BCIs around AP. Few studies were identified; most were suboptimal in theory use. There is a need to consider how theory is used and reported and the systematic use of the TCS could help.

Safety of reducing antibiotic prescribing in primary care: a mixed-methods study

Background

The threat of antimicrobial resistance has led to intensified efforts to reduce antibiotic utilisation, but serious bacterial infections are increasing in frequency.

Objectives

To estimate the risks of serious bacterial infections in association with lower antibiotic prescribing and understand stakeholder views with respect to safe antibiotic reduction.

Design

Mixed-methods research was undertaken, including a qualitative interview study of patient and prescriber views that informed a cohort study and a decision-analytic model, using primary care electronic health records. These three work packages were used to design an application (app) for primary care prescribers.

Data sources

The Clinical Practice Research Datalink.

Setting

This took place in UK general practices.

Participants

A total of 706 general practices with 66.2 million person-years of follow-up from 2002 to 2017 and antibiotic utilisation evaluated for 671,830 registered patients. The qualitative study included 31 patients and 30 health-care professionals from primary care.

Main outcome measures

Sepsis and localised bacterial infections.

Results

Patients were concerned about antimicrobial resistance and the side effects, as well as the benefits, of antibiotic treatment. Prescribers viewed the onset of sepsis as the most concerning potential outcome of reduced antibiotic prescribing. More than 40% of antibiotic prescriptions in primary care had no coded indication recorded across both Vision® and EMIS® practice systems. Antibiotic prescribing rates varied widely between general practices, but there was no evidence that serious bacterial infections were less frequent at higher prescribing practices (adjusted rate ratio for 20% increase in prescribing 1.03, 95% confidence interval 1.00 to 1.06; p = 0.074). The probability of sepsis was lower if an antibiotic was prescribed at an infection consultation, and the number of antibiotic prescriptions required to prevent one episode of sepsis (i.e. the number needed to treat) decreased with age. For those aged 0–4 years, the number needed to treat was 29,773 (95% uncertainty interval 18,458 to 71,091) in boys and 27,014 (95% uncertainty interval 16,739 to 65,709) in girls. For those aged > 85 years, the number needed to treat was 262 (95% uncertainty interval 236 to 293) in men and 385 (95% uncertainty interval 352 to 421) in women. Frailty was associated with a greater risk of sepsis and a smaller number needed to treat. For severely frail patients aged 55–64 years, the number needed to treat was 247 (95% uncertainty interval 156 to 459) for men and 343 (95% uncertainty interval 234 to 556) for women. At all ages, the probability of sepsis was greatest for urinary tract infection, followed by skin infection and respiratory tract infection. The numbers needed to treat were generally smaller for the period 2014–17, when sepsis was diagnosed more frequently. The results are available using an app that we developed to provide primary care prescribers with stratified risk estimates during infection consultations.

Limitations

Analyses were based on non-randomised comparisons. Infection episodes and antibiotic prescribing are poorly documented in primary care.

Conclusions

Antibiotic treatment is generally associated with lower risks, but the most serious bacterial infections remain infrequent even without antibiotic treatment. This research identifies risk strata in which antibiotic prescribing can be more safely reduced.

Future work

The software developed from this research may be further developed and investigated for antimicrobial stewardship effect.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 9. See the NIHR Journals Library website for further project information.

Factors associated with independent nurse prescribers' antibiotic prescribing practice: a mixed-methods study using the Reasoned Action Approach

BACKGROUND

The number of nurse prescribers is increasing, yet little evidence exists about their antibiotic prescribing behaviour.

AIM

To measure nurse independent prescribers' (NIPs) intention to manage patients, presenting with an upper respiratory tract infection (URTI) for the first time, without prescribing an antibiotic and to examine the determinants of this behaviour.

METHODS

This was a mixed-method study using the Reasoned Action Approach (RAA). Content analysis of data from 27 telephone interviews with NIPs informed the development of a questionnaire which was tested for validity and reliability and used in a national survey of NIPs across Scotland. Descriptive and inferential statistical analysis was carried out to determine intention to manage patients without prescribing an antibiotic and the significant influences on this intention.

FINDINGS

From 184 participants it was found that NIPs intended to manage patients, presenting with a URTI for the first time, without prescribing an antibiotic. Key determinants were perceived norm, perceived behavioural control, and moral norm. Significant beliefs were positive social influence from other non-medical prescribers (P = 0.007) and nurse prescribers (P = 0.045), the enablers of prescriber experience and confidence (P ≤ 0.001), and the barrier of pressure from patients/carers (P = 0.010).

CONCLUSION

The findings provide reassurance that NIPs intend to prescribe appropriately. The identification of nurse-specific barriers and enablers to this intention should be acknowledged and targeted in future interventions to manage this behaviour.

Optimising antimicrobial stewardship interventions in English primary care: a behavioural analysis of qualitative and intervention studies

OBJECTIVE

While various interventions have helped reduce antibiotic prescribing, further gains can be made. This study aimed to identify ways to optimise antimicrobial stewardship (AMS) interventions by assessing the extent to which important influences on antibiotic prescribing are addressed (or not) by behavioural content of AMS interventions.

SETTINGS

English primary care.

INTERVENTIONS

AMS interventions targeting healthcare professionals' antibiotic prescribing for respiratory tract infections.

METHODS

We conducted two rapid reviews. The first included qualitative studies with healthcare professionals on self-reported influences on antibiotic prescribing. The influences were inductively coded and categorised using the Theoretical Domains Framework (TDF). Prespecified criteria were used to identify key TDF domains. The second review included studies of AMS interventions. Data on effectiveness were extracted. Components of effective interventions were extracted and coded using the TDF, Behaviour Change Wheel and Behaviour Change Techniques (BCTs) taxonomy. Using prespecified matrices, we assessed the extent to which BCTs and intervention functions addressed the key TDF domains of influences on prescribing.

RESULTS

We identified 13 qualitative studies, 41 types of influences on antibiotic prescribing and 6 key TDF domains of influences: 'beliefs about consequences', 'social influences', 'skills', 'environmental context and resources', 'intentions' and 'emotions'. We identified 17 research-tested AMS interventions; nine of them effective and four nationally implemented. Interventions addressed all six key TDF domains of influences. Four of these six key TDF domains were addressed by 50%-67% BCTs that were theoretically congruent with these domains, whereas TDF domain 'skills' was addressed by 24% of congruent BCTs and 'emotions' by none.

CONCLUSIONS

Further improvement of antibiotic prescribing could be facilitated by: (1) national implementation of effective research-tested AMS interventions (eg, electronic decision support tools, training in interactive use of leaflets, point-of-care testing); (2) targeting important, less-addressed TDF domains (eg, 'skills', 'emotions'); (3) using relevant, under-used BCTs to target key TDF domains (eg, 'forming/reversing habits', 'reducing negative emotions', 'social support'). These could be incorporated into existing, or developed as new, AMS interventions.

Revisiting patient expectations and experiences of antibiotics in an era of antimicrobial resistance: Qualitative study

OBJECTIVE

To investigate contemporary patient expectations and experiences of antibiotic prescribing in England.

BACKGROUND

Primary care providers' compliance with patient influences has been identified as a motivation for antibiotic-prescribing behaviour. Since 2013, there have been concerted efforts to publicize and address the growing threat of antimicrobial resistance. A fresh qualitative insight into patient expectations and experiences is needed.

DESIGN

Qualitative study using semi-structured interviews.

SETTING AND PARTICIPANTS

Two English regions, one an urban metropolitan area and the other a town in rural England. Patients who recently consulted for infections were recruited. The information power approach was used to determine the number of participants, yielding a sample of 31 participants.

MAIN MEASURES

Thematic analysis was carried out to analyse the interview data.

RESULTS

Five themes were identified: beliefs, expectations, experiences of taking antibiotic, experience of antimicrobial resistance and side-effects, and experiences of consultations. The accounts reflected improved public knowledge: antibiotics were perceived to be much-needed medicines that should be prescribed when appropriate. The data showed that patients formed expectations of expectations, trying to read the prescribers' intentions and reflect on the dependency between what prescribers and patients wanted. Patient experiences featured as nuanced and detailed with knowledge of AMR and side-effects of antibiotics in the context of positive consultation experiences.

CONCLUSIONS

The study highlighted complex interplays between adherence to antibiotics and consuming antibiotics in reflexive, informed ways. Ensuring that present and future patients are informed about potential benefits and harms of antibiotic use will contribute to future antimicrobial stewardship.

Understanding the impact of a new pharmacy sore throat test and treat service on patient experience: A survey study

BACKGROUND

A pilot of the first NHS funded Sore Throat Test and Treat (STTT) service in the United Kingdom began in selected community pharmacies in Wales in November 2018. The aim of this research was to explore whether a pharmacist delivering consultation for sore throat that included clinical scoring and point-of-care testing was acceptable to patients and how this might influence future health-seeking behaviour.

METHODS

A non-experimental design was employed using a survey research tool including a mix of closed and open questions. The patient experience survey was distributed to all patients who had completed a consultation between November 2018 and May 2019. Data from completed surveys were entered in Jisc Online Surveys® and exported to Excel® for descriptive statistics. Free-text comments were analysed using content and inductive thematic analysis.

RESULTS

A total of 510 surveys were received (n = 2,839 total consultations, response rate 18%). Overall, 501 patients (98%) were satisfied with the service. Patients' confidence in managing their condition and service satisfaction was not dependent on having been supplied antibiotics. After the service, 504 patients (99%) stated that they would return to the pharmacy for subsequent sore throat symptoms. Three themes were constructed after inductive analysis of free-text comments (n = 242): convenience and accessibility; professionalism of pharmacy team; and perceived value of the service.

CONCLUSIONS

Results confirmed high levels of patient satisfaction with the new service, its delivery and the choice of options offered for sore throat symptom management. Whilst this research can only discuss patients' reported future behaviour, the patient-reported stated intentions signify a potential shift in health-seeking behaviour towards a pharmacist-led service. This has important implications in supporting the long-term plan of the governments in Wales and England to redirect management of uncomplicated conditions from GPs to pharmacies.

Community Pharmacist Views On The Early Stages Of Implementation Of A Pathfinder Sore Throat Test And Treat Service In Wales: An Exploratory Study

OBJECTIVES

To explore the views and opinions of community pharmacists regarding their initial experience of and levels of preparedness for the pathfinder sore throat test and treat (STTT) service in Wales.

METHODS

A phenomenological qualitative approach with constructivist paradigm was adopted as the first cycle of ongoing action research. Semi-structured interviews with community pharmacists who had completed at least three consultations within the first 3 weeks of the service were conducted, with informed consent and audio recorded. Interviews were transcribed ad verbatim and data were thematically analysed both inductively and deductively.

RESULTS

A total of seven interviews with pharmacists who had conducted more than three consultations identified three main themes: 1) perceived impact of the service on patient care, including the value of the structure and technology infrastructure, the role of STTT towards antimicrobial stewardship, and its potential role in rebalancing primary care resources so that workload is distributed appropriately among healthcare professionals; 2) factors that empower pharmacists to deliver the service, in particular quality and consistency of training, appropriate staffing resource and internally motivated willingness to engage; 3) interface with GP surgeries such as nature of existing relationships before implementing the service, role of GP staff and GP perceived value of STTT.

CONCLUSION

The pathfinder STTT service has been well received by pharmacists who recognised the service's role in providing patient education and contributing to principles of antimicrobial stewardship and described factors that would empower them to deliver the service confidently. Results have been fed back to the service implementation team to inform future developments.

Theory-based electronic learning intervention to support appropriate antibiotic prescribing by nurses and pharmacists: intervention development and feasibility study protocol

INTRODUCTION

Nurse and pharmacist independent prescribers manage patients with respiratory tract infections and are responsible for around 8% of all primary care antibiotic prescriptions. A range of factors influence the prescribing behaviour of these professionals, however, there are no interventions available specifically to support appropriate antibiotic prescribing behaviour by these groups. The aims of this paper are to describe (1) the development of an intervention to support appropriate antibiotic prescribing by nurse and pharmacist independent prescribers and (2) an acceptability and feasibility study designed to test its implementation with these prescribers. METHOD AND ANALYSIS: Development of intervention: a three-stage, eight-step method was used to identify relevant determinants of behaviour change and intervention components based on the Behaviour Change Wheel. The intervention is an online resource comprising underpinning knowledge and an interactive animation with a variety of open and closed questions to assess understanding. Acceptability and feasibility of intervention: nurse and pharmacist prescribers (n=12-15) will use the intervention. Evaluation includes semi-structured interviews to capture information about how the user reacts to the design, delivery and content of the intervention and influences on understanding and engagement, and a pre-post survey to assess participants' perceptions of the impact of the intervention on knowledge, confidence and usefulness in terms of application to practice. Taking an initial inductive approach, data from interview transcripts will be coded and then analysed to derive themes. These themes will then be deductively mapped to the Capability, Opportunity, Motivation-Behaviour model. Descriptive statistics will be used to analyse the survey data, and trends identified.

ETHICS AND DISSEMINATION

Ethical approval for the study has been provided by the School of Healthcare Sciences Research Governance and Ethics Committee, Cardiff University. The findings will be disseminated via publication in peer-reviewed journals and through conference presentations.

Community nursing and antibiotic stewardship: the importance of communication and training

Antimicrobial stewardship (using antimicrobials responsibly) can reduce the risk of antimicrobial resistance (AMR). Many health professionals identify themselves as 'antibiotic guardians', but patient expectations, time constraints, and a lack of confidence or underdeveloped communication skills can influence decisions to prescribe. Nurse prescribers have an important role to play in antibiotic stewardship, and their numbers continue to grow. While nurse prescribers welcome this extension to their traditional role, they are often faced with barriers to antibiotic stewardship activities. These barriers may relate to their Capability (knowledge/skill), Opportunity (norms of practice, influence of patients, environmental factors), and Motivation (attitudes and beliefs, concern over outcome, emotion and habit) [COM-B]. Education, training and enablement can help to overcome these barriers, and the development of knowledge, confidence and effective communication skills should be of priority. Further, communication skills can help nurse prescribers understand patient expectations, with the use of open-ended questions, active listening and creation of a patient-centred consultation that leads to a mutually agreed end goal and way forward.

Examining influences on antibiotic prescribing by nurse and pharmacist prescribers: a qualitative study using the Theoretical Domains Framework and COM-B

OBJECTIVES

Respiratory tract infections are frequently managed by nurse and pharmacist prescribers, and these prescribers are responsible for 8% of all primary care antibiotic prescriptions. Few studies have explored antibiotic prescribing among these prescribers, and interventions to target their antibiotic prescribing behaviour do not exist. Research objectives were to: (1) use the Theoretical Domains Framework to identify the factors that influence nurse and pharmacist prescriber management of respiratory tract infections and (2) identify the behaviour change techniques (BCTs) that can be used as the basis for the development of a theoretically informed intervention to support appropriate prescribing behaviour.

DESIGN

Qualitative design comprising semistructured interviews, using the Theoretical Domains Framework and Capability, Opportunity and Motivation for Behaviour.

SETTING

Primary care.

PARTICIPANTS

Twenty one prescribers (4 pharmacists and 17 nurses).

RESULTS

A range of factors across 12 domains of the TDF were found to influence prescriber behaviour, and 40 BCTs were identified as supporting appropriate prescribing. For example, patient expectations (social influence) was identified as a factor influencing prescribing decisions, and a number of BCTs (problem solving, goal setting and information about health consequences) were identified as supporting prescribers in managing these expectations.

CONCLUSION

With increasing numbers of nurse and pharmacist prescribers managing infections in primary care, these findings will inform theoretically grounded interventions to support appropriate prescribing behaviour by these groups.

Patients with respiratory tract infections who do not want antibiotics: direct observational study of primary care in Poland

BACKGROUND

Requests by patients for antibiotics are known to strongly affect doctors' decisions to prescribe them.Objective. The aim of this study was to establish how frequently patients presenting with respiratory tract infections (RTIs) express their expectation not to be treated with antibiotics, which symptoms and physical findings are related to their perception of antibiotics not being helpful, and to what degree their expectations influence doctors' decisions.

METHODS

This was a direct observational study set in primary care practices in Bialystok, Poland. The observers completed a checklist while observing a patient with RTI visiting a family doctor.

RESULTS

Overall, 80 (5.5%) out of 1456 patients with RTIs openly requested not to be prescribed antibiotics. Patients not wanting antibiotics were prescribed antibiotics significantly less frequently [25/80 (31.3%)] than the remaining patients [765/1376 (55.6%), P < 0.001]. Univariate logistic regression revealed that cough and runny nose significantly increased the odds of patients not wanting antibiotics [odds ratio (OR) 1.8, 95% confidence intervals (CI): 1.01-3.20 and OR 1.6, 95% CI: 1.01-2.6, respectively] while the presence of tonsillar exudates significantly decreased the odds (OR 0.3, 95% CI: 0.08-0.86). Belief in a self-limited course (20%), recent treatments with antibiotics (16.3%), suspected viral aetiology (12.5%), and concerns about possible harm (12.5%) were the principal reasons for not wanting antibiotics.

CONCLUSIONS

A patient's wish not to be prescribed antibiotics leads to less frequent antibiotic prescribing. Antimicrobial resistance, though important from a public health viewpoint, is not seen as a priority for individual patients with infections.

Medical management of acute upper respiratory infections in an urban primary care out-of-hours facility: cross-sectional study of patient presentations and expectations

OBJECTIVES

The purpose of this study was to examine the expectations of patients attending an urban primary care out-of-hours (OOH) facility with acute upper respiratory tract infection (acute URTI) regarding clinical examination, symptom management, information on their condition, reassurance, antibiotic treatment and other possible options including referral.

DESIGN

Cross-sectional design.

SETTING

One urban primary care OOH facility located in the midwest of Ireland.

PARTICIPANTS

457 patients filled out a questionnaire while waiting in the OOH facility; 22 surveys were excluded as the patients did not present with symptoms of acute URTI resulting in 435 patients' data being included in this study. There were 59.5% female participants and 40.5% male participants.

RESULTS

435 patients with acute URTI symptoms participated in the survey, representing 25.4% of those attending the single branch where the survey was conducted (n=1715). Of the study participants, 43% were aged under 6 years and 60% were women. The most common presenting symptoms were cough (72%), throat ache (46%) and common cold (26%). The most common expectations were for further examination (53%), reassurance (51%), information (49%) and medication for cough (47%), with 34% expecting an antibiotic.

CONCLUSIONS

Only one in three patients attending this primary care OOH facility with acute URTI symptoms had an expectation of antibiotics, with most seeking further assessment, information and reassurance. Recognition of such expectations may be important considerations for clinicians when deciding on management options for patients with acute URTI.

Over prescribing of antibiotics for acute respiratory tract infections; a qualitative study to explore Irish general practitioners' perspectives

BACKGROUND

Anti-microbial resistance (AMR) is a global threat to public health and antibiotics are often unnecessarily prescribed for acute respiratory tract infections (ARTIs) in general practice. We aimed to investigate why general practitioners (GPs) continue to prescribe antibiotics for ARTIs despite increasing knowledge of their poor efficacy and worsening antimicrobial resistance.

METHODS

We used an explorative qualitative study design. Thirteen GPs were recruited through purposive sampling to represent urban and rural settings and years of experience. They were based in general practices within the Mid-West of Ireland. GPs took part in semi-structured interviews that were digitally audio recorded and transcribed.

RESULTS

Three main themes and three subthemes were identified. Themes include (1) non-comprehensive guidelines; how guideline adherence can be difficult, (2) GPs under pressure; pressures to prescribe from patients and perceived patient expectations and (3) Unnecessary prescribing; how to address it and the potential of public interventions to reduce it.

CONCLUSIONS

GPs acknowledge their failure to implement guidelines because they feel they are less usable in clinical situations. GPs felt pressurised to prescribe, especially for fee-paying patients and in out of hours settings (OOH), suggesting the need for interventions that target the public's perceptions of antibiotics. GPs behaviours surrounding prescribing antibiotics need to change in order to reduce AMR and change patients' expectations.

Qualitative study using interviews and focus groups to explore the current and potential for antimicrobial stewardship in community pharmacy informed by the Theoretical Domains Framework

OBJECTIVES

Community pharmacists and their staff have the potential to contribute to antimicrobial stewardship (AMS). However, their barriers and opportunities are not well understood. The aim was to investigate the experiences and perceptions of community pharmacists and their teams around AMS to inform intervention development.

DESIGN

Interviews and focus groups were used to explore the views of pharmacists, pharmacy staff, general practitioners (GPs), members of pharmacy organisations and commissioners. The questioning schedule was developed using the Theoretical Domains Framework which helped inform recommendations to facilitate AMS in community pharmacy.

RESULTS

8 GPs, 28 pharmacists, 13 pharmacy staff, 6 representatives from pharmacy organisations in England and Wales, and 2 local stakeholders participated.Knowledge and skills both facilitated or hindered provision of self-care and compliance advice by different grades of pharmacy staff. Some staff were not aware of the impact of giving self-care and compliance advice to help control antimicrobial resistance (AMR). The pharmacy environment created barriers to AMS; this included lack of time of well-qualified staff leading to misinformation from underskilled staff to patients about the need for antibiotics or the need to visit the GP, this was exacerbated by lack of space. AMS activities were limited by absent diagnoses on antibiotic prescriptions.Several pharmacy staff felt that undertaking patient examinations, questioning the rationale for antibiotic prescriptions and performing audits would allow them to provide more tailored AMS advice.

CONCLUSIONS

Interventions are required to overcome a lack of qualified staff, time and space to give patients AMS advice. Staff need to understand how self-care and antibiotic compliance advice can help control AMR. A multifaceted educational intervention including information for staff with feedback about the advice given may help. Indication for a prescription would enable pharmacists to provide more targeted antibiotic advice. Commissioners should consider the pharmacists' role in examining patients, and giving advice about antibiotic prescriptions.

Antibiotic use for acute respiratory tract infections (ARTI) in primary care; what factors affect prescribing and why is it important? A narrative review

BACKGROUND

Antimicrobial resistance is an emerging global threat to health and is associated with increased consumption of antibiotics. Seventy-four per cent of antibiotic prescribing takes place in primary care. Much of this is for inappropriate treatment of acute respiratory tract infections.

AIMS

To review the published literature pertaining to antibiotic prescribing in order to identify and understand the factors that affect primary care providers' prescribing decisions.

METHODS

Six online databases were searched for relevant paper using agreed criteria. One hundred ninety-five papers were retrieved, and 139 were included in this review.

RESULTS

Primary care providers are highly influenced to prescribe by patient expectation for antibiotics, clinical uncertainty and workload induced time pressures. Strategies proven to reduce such inappropriate prescribing include appropriately aimed multifaceted educational interventions for primary care providers, mass media educational campaigns aimed at healthcare professionals and the public, use of good communication skills in the consultation, use of delayed prescriptions especially when accompanied by written information, point of care testing and, probably, longer less pressurised consultations. Delayed prescriptions also facilitate focused personalised patient education.

CONCLUSION

There is an emerging consensus in the literature regarding strategies proven to reduce antibiotic consumption for acute respiratory tract infections. The widespread adoption of these strategies in primary care is imperative.

An overview of developments in nurse prescribing in the UK

In the UK and internationally, the nursing profession is continuing to advance and innovate its roles and functions. One area in which this is particularly notable is nurse prescribing. The UK has the most extended nurse prescribing rights in the world, with significant advances in this field over the past two decades. This article reflects on this development, what has been learned and the challenges that remain in relation to nurse prescribing and meeting healthcare service needs.

General practitioner and nurse prescriber experiences of prescribing antibiotics for respiratory tract infections in UK primary care out-of-hours services (the UNITE study)

Background

Interventions are needed to reduce unnecessary antibiotic prescribing for respiratory tract infections (RTIs). Although community antibiotic prescribing appears to be decreasing in the UK, figures for out-of-hours (OOH) prescribing have substantially increased. Understanding the factors influencing prescribing in OOH and any perceived differences between general practitioner (GP) and nurse prescriber (NP) prescribing habits may enable the development of tailored interventions promoting optimal prescribing in this setting.

Objectives

To explore UK GP and NP views on and experiences of prescribing antibiotics for RTIs in primary care OOH services.

Methods

Thirty semi-structured interviews were conducted with GPs and NPs working in primary care OOH services. Inductive thematic analysis was used to analyse data.

Results

The research shows that factors particular to OOH influence antibiotic prescribing, including a lack of patient follow-up, access to patient GP records, consultation time, working contracts and implementation of feedback, audit and supervision. NPs reported perceptions of greater accountability for their prescribing compared with GPs and reported they had longer consultations during which they were able to discuss decisions with patients. Participants agreed that more complex cases should be seen by GPs and highlighted the importance of consistency of decision making, illness explanations to patients as well as a perception that differences in clinical training influence communication with patients and antibiotic prescribing decisions.

Conclusions

Environmental and social factors in OOH services and a mixed healthcare workforce provide unique influences on antibiotic prescribing for RTIs, which would need to be considered in tailoring interventions that promote prudent antibiotic prescribing in OOH services.

How patients' experiences of respiratory tract infections affect healthcare-seeking and antibiotic use: insights from a cross-sectional survey in rural Anhui, China

OBJECTIVE

To investigate the occurrence of reported respiratory tract infection (RTI) symptoms and their effects on use of self and professional care among patients in the community.

DESIGN

A cross-sectional retrospective household survey.

SETTING

12 administrative villages from rural Anhui, China.

PARTICIPANTS

2160 rural adult residents aged ≥18 years registered as rural residents and actually living in the sampled villages when this study was conducted.

METHOD

The respondents were recruited using stratified-clustered randomised sampling. A structured questionnaire was deployed to solicit information about social demographics, symptoms of last RTI and healthcare-seeking following the RTI. Descriptive analyses were performed to investigate the reported symptoms, and multivariate logistic regression models were developed to identify relationships between number of concurrent symptoms and healthcare-seeking and antibiotics use.

RESULTS

A total of 1968 residents completed the survey, resulting in a response rate of 91.1%. The number of concurrent symptoms showed a clear increasing trend with seeking help from clinics and being prescribed antibiotics. Multivariate regression revealed statistically significant associations between the following: (a) visiting clinics and education (OR=0.790), sore throat (OR=1.355), cough (OR=1.492), shortness of breath (OR=1.707) and fever (OR=2.142); (b) buying medicine from shops without prescription and education (OR=1.230) and cough (OR=1.452); (c) getting antibiotics at clinics and sore throat (OR=2.05) and earache and/or tinnitus (OR=4.884); and (d) obtaining antibiotics at medicine shops and productive cough (OR=1.971).

CONCLUSIONS

Reported RTI symptoms play an important role in shaping both patient- and doctor-led responses.