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Babarczy B, Hajdu Á, Benko R, Matuz M, Papp R, Antoniou P, Kandelaki K, Lo Fo Wong D, Warsi SK. Hungarian general practice paediatricians' antibiotic prescribing behaviour for suspected respiratory tract infections: a qualitative study. BMJ Open 2024; 14:e081574. [PMID: 38729758 PMCID: PMC11097800 DOI: 10.1136/bmjopen-2023-081574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 03/08/2024] [Indexed: 05/12/2024] Open
Abstract
OBJECTIVES Inappropriate antibiotic prescribing is a major cause of antimicrobial resistance (AMR). The aim of this study was to explore paediatric general practitioners' (GP Peds) antibiotic prescription practice in suspected respiratory tract infections (RTIs), using the capability-opportunity-motivation-behaviour framework. DESIGN The design is a qualitative study based on individual, semistructured telephone or virtual interviews. SETTING Paediatric general practice in Hungary. We applied stratified maximum variation sampling to cover the categories of age, sex and geographical location of participants. PARTICIPANTS We interviewed 22 GP Peds. Nine were male and 13 were female: 2 of them were less than 40 years old, 14 were between 40 and 60 years, and 6 were above 60 years. 10 worked in low-antibiotic prescription areas, 5 in areas with medium levels of antibiotic prescription, 3 in high-antibiotic prescription areas, and 4 in and around the capital city. RESULTS Study participants had varying antibiotic prescription preferences. Personal experience and physical examination play a central role in GP Peds' diagnostic and treatment practice. Participants emphasised the need to treat children in their entirety, taking their personal medical record, social background and sometimes parents' preferences into account, besides the acute clinical manifestation of RTI. Most respondents were confident they apply the most effective therapy even if, in some cases, this meant prescribing medicines with a higher chance of contributing to the development of AMR. Some participants felt antibiotic prescription frequency has decreased in recent years. CONCLUSIONS Our findings suggest that a more prudent attitude toward antibiotic prescribing may have become more common but also highlight relevant gaps in both physicians' and public knowledge of antibiotics and AMR. To reinforce awareness and close remaining gaps, Hungary should adopt its national AMR National Action Plan and further increase its efforts towards active professional communication and feedback for primary care physicians.
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Affiliation(s)
- Balázs Babarczy
- Syreon Research Institute, Budapest, Hungary
- National Center for Public Health and Pharmacy, Budapest, Hungary
| | - Ágnes Hajdu
- National Center for Public Health and Pharmacy, Budapest, Hungary
| | - Ria Benko
- Department of Clinical Pharmacy, University of Szeged, Szeged, Hungary
| | - Mária Matuz
- Department of Clinical Pharmacy, University of Szeged, Szeged, Hungary
| | - Renáta Papp
- Centre of Science & Innovation Vice-rector and Business Development, Semmelweis University, Budapest, Hungary
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2
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Nielsen ND, Dean JT, Shald EA, Conway Morris A, Povoa P, Schouten J, Parchim N. When to Stop Antibiotics in the Critically Ill? Antibiotics (Basel) 2024; 13:272. [PMID: 38534707 DOI: 10.3390/antibiotics13030272] [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: 01/31/2024] [Revised: 03/03/2024] [Accepted: 03/14/2024] [Indexed: 03/28/2024] Open
Abstract
Over the past century, antibiotic usage has skyrocketed in the treatment of critically ill patients. There have been increasing calls to establish guidelines for appropriate treatment and durations of antibiosis. Antibiotic treatment, even when appropriately tailored to the patient and infection, is not without cost. Short term risks-hepatic/renal dysfunction, intermediate effects-concomitant superinfections, and long-term risks-potentiating antimicrobial resistance (AMR), are all possible consequences of antimicrobial administration. These risks are increased by longer periods of treatment and unnecessarily broad treatment courses. Recently, the literature has focused on multiple strategies to determine the appropriate duration of antimicrobial therapy. Further, there is a clinical shift to multi-modal approaches to determine the most suitable timepoint at which to end an antibiotic course. An approach utilising biomarker assays and an inter-disciplinary team of pharmacists, nurses, physicians, and microbiologists appears to be the way forward to develop sound clinical decision-making surrounding antibiotic treatment.
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Affiliation(s)
- Nathan D Nielsen
- Division of Pulmonary, Critical Care and Sleep Medicine, University of New Mexico School of Medicine, Albuquerque, NM 87131, USA
- Section of Transfusion Medicine and Therapeutic Pathology, University of New Mexico School of Medicine, Albuquerque, NM 87131, USA
| | - James T Dean
- Division of Pulmonary, Critical Care and Sleep Medicine, University of New Mexico School of Medicine, Albuquerque, NM 87131, USA
| | - Elizabeth A Shald
- Department of Pharmacy, University of New Mexico Hospital, Albuquerque, NM 87131, USA
| | - Andrew Conway Morris
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge CB2 0QQ, UK
- Division of Immunology, Department of Pathology, University of Cambridge, Cambridge CB2 1QP, UK
- JVF Intensive Care Unit, Addenbrooke's Hospital, Cambridge CB2 0QQ, UK
| | - Pedro Povoa
- NOVA Medical School, NOVA University of Lisbon, 1169-056 Lisbon, Portugal
- Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, OUH Odense University Hospital, 5000 Odense, Denmark
- Department of Intensive Care, Hospital de São Francisco Xavier, CHLO, 1449-005 Lisbon, Portugal
| | - Jeroen Schouten
- Department of Intensive Care Medicine, Radboud MC, 6525 GA Nijmegen, The Netherlands
| | - Nicholas Parchim
- Division of Critical Care, Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, NM 87131, USA
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3
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Sievert EDC, Korn L, Gross M, Santana AP, Böhm R, Betsch C. Communicating diagnostic uncertainty reduces expectations of receiving antibiotics: Two online experiments with hypothetical patients. Appl Psychol Health Well Being 2024. [PMID: 38500005 DOI: 10.1111/aphw.12536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 02/13/2024] [Indexed: 03/20/2024]
Abstract
The overprescription of antibiotics due to diagnostic uncertainty and inappropriate patient expectations influence antimicrobial resistance. This research assesses (i) whether communicating diagnostic uncertainty reduces expectations of receiving antibiotics and (ii) which communication strategies minimise unintended consequences of such communication. In two experimental online studies conducted in January and April 2023, participants read a vignette describing a doctor consultation for an ear infection and expressed their expectations of receiving antibiotics, trust in their doctor, rated the doctor's reputation and provided their intention to get a second doctor's opinion. Study 1 (N = 2213) investigated whether communicating diagnostic uncertainty and social externalities of antibiotic use (the negative social impacts of developing antibiotic resistance) decreases expectations for antibiotics and explores potential unintended consequences on the doctor-patient relationship. In Study 2 (N = 527), we aimed to replicate and extend the findings by adding specific treatment recommendations. Disclosing diagnostic uncertainty (vs. certainty) and communicating (vs. not communicating) the social externalities of antibiotic overuse reduced patients' expectations of receiving antibiotics. Yet, communicating uncertainty impaired trust in the doctor and the doctor's reputation. Combining the communication of uncertainty with specific treatment recommendations-particularly delayed antibiotic prescriptions-showed important to prevent these unintended consequences.
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Affiliation(s)
- Elisabeth D C Sievert
- Health Communication, Institute for Planetary Health Behaviour, University of Erfurt, Erfurt, Germany
- Health Communication, Implementation Research, Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany
| | - Lars Korn
- Health Communication, Institute for Planetary Health Behaviour, University of Erfurt, Erfurt, Germany
- Health Communication, Implementation Research, Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany
| | - Marina Gross
- Faculty of Psychology, University of Vienna, Vienna, Austria
| | - Ana Paula Santana
- Department of Psychology, University of Copenhagen, Copenhagen, Denmark
| | - Robert Böhm
- Faculty of Psychology, University of Vienna, Vienna, Austria
- Department of Psychology, University of Copenhagen, Copenhagen, Denmark
- Copenhagen Center for Social Data Science (SODAS), University of Copenhagen, Copenhagen, Denmark
| | - Cornelia Betsch
- Health Communication, Institute for Planetary Health Behaviour, University of Erfurt, Erfurt, Germany
- Health Communication, Implementation Research, Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany
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4
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Stewart SJF, Pandolfo AM, Moon Z, Jani Y, Brett SJ, Brealey D, Singh S, Enne VI, Livermore DM, Gant V, Horne R. UK clinicians' attitudes towards the application of molecular diagnostics to guide antibiotic use in ICU patients with pneumonias: a quantitative study. J Antimicrob Chemother 2024; 79:123-127. [PMID: 37970680 PMCID: PMC10761255 DOI: 10.1093/jac/dkad355] [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] [Received: 04/25/2023] [Accepted: 10/13/2023] [Indexed: 11/17/2023] Open
Abstract
BACKGROUND Molecular diagnostic tests may improve antibiotic prescribing by enabling earlier tailoring of antimicrobial therapy. However, clinicians' trust and acceptance of these tests will determine their application in practice. OBJECTIVES To examine ICU prescribers' views on the application of molecular diagnostics in patients with suspected hospital-acquired and ventilator-associated pneumonia (HAP/VAP). METHODS Sixty-three ICU clinicians from five UK hospitals completed a cross-sectional questionnaire between May 2020 and July 2020 assessing attitudes towards using molecular diagnostics to inform initial agent choice and to help stop broad-spectrum antibiotics early. RESULTS Attitudes towards using molecular diagnostics to inform initial treatment choices and to stop broad-spectrum antibiotics early were nuanced. Most (83%) were positive about molecular diagnostics, agreeing that using results to inform broad-spectrum antibiotic prescribing is good practice. However, many (58%) believed sick patients are often too unstable to risk stopping broad-spectrum antibiotics based on a negative result. CONCLUSIONS Positive attitudes towards the application of molecular diagnostics to improve antibiotic stewardship were juxtapositioned against the perceived need to initiate and maintain broad-spectrum antibiotics to protect unstable patients.
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Affiliation(s)
| | - Alyssa M Pandolfo
- Centre for Behavioural Medicine, University College London, London, UK
| | - Zoe Moon
- Centre for Behavioural Medicine, University College London, London, UK
| | - Yogini Jani
- Centre for Behavioural Medicine, University College London, London, UK
- UCLH-UCL Centre for Medicines Optimisation Research and Education, University College London Hospitals NHS Foundation Trust, London, UK
| | - Stephen J Brett
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - David Brealey
- Division of Critical Care, University College London Hospitals NHS Foundation Trust, London, UK
| | - Suveer Singh
- Department of Respiratory and Critical Care Medicine, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
- Faculty of Medicine, Imperial College London, London, UK
| | - Virve I Enne
- Division of Infection and Immunity, University College London, London, UK
| | - David M Livermore
- Norwich Medical School, University of East Anglia, Norwich, Norfolk, UK
| | - Vanya Gant
- Department of Medical Microbiology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Robert Horne
- Centre for Behavioural Medicine, University College London, London, UK
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Janssen RME, Oerlemans AJM, van der Hoeven JG, Oostdijk EAN, Derde LPG, Ten Oever J, Wertheim HFL, Hulscher MEJL, Schouten JA. Decision-making regarding antibiotic therapy duration: An observational study of multidisciplinary meetings in the intensive care unit. J Crit Care 2023; 78:154363. [PMID: 37393864 DOI: 10.1016/j.jcrc.2023.154363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 05/05/2023] [Accepted: 06/17/2023] [Indexed: 07/04/2023]
Abstract
PURPOSE Antibiotic therapy is commonly prescribed longer than recommended in intensive care patients (ICU). We aimed to provide insight into the decision-making process on antibiotic therapy duration in the ICU. METHODS A qualitative study was conducted, involving direct observations of antibiotic decision-making during multidisciplinary meetings in four Dutch ICUs. The study used an observation guide, audio recordings, and detailed field notes to gather information about the discussions on antibiotic therapy duration. We described the participants' roles in the decision-making process and focused on arguments contributing to decision-making. RESULTS We observed 121 discussions on antibiotic therapy duration in sixty multidisciplinary meetings. 24.8% of discussions led to a decision to stop antibiotics immediately. In 37.2%, a prospective stop date was determined. Arguments for decisions were most often brought forward by intensivists (35.5%) and clinical microbiologists (22.3%). In 28.9% of discussions, multiple healthcare professionals participated equally in the decision. We identified 13 main argument categories. While intensivists mostly used arguments based on clinical status, clinical microbiologists used diagnostic results in the discussion. CONCLUSIONS Multidisciplinary decision-making regarding the duration of antibiotic therapy is a complex but valuable process, involving different healthcare professionals, using a variety of argument-types to determine the duration of antibiotic therapy. To optimize the decision-making process, structured discussions, involvement of relevant specialties, and clear communication and documentation of the antibiotic plan are recommended.
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Affiliation(s)
- Robin M E Janssen
- Radboud university medical center, Department of Intensive Care Medicine, Nijmegen, the Netherlands; Radboud university medical center, Scientific Center for Quality of Healthcare (IQ healthcare), Nijmegen, the Netherlands; Radboud university medical center, Radboud Center for Infectious Diseases (RCI), Nijmegen, the Netherlands.
| | - Anke J M Oerlemans
- Radboud university medical center, Scientific Center for Quality of Healthcare (IQ healthcare), Nijmegen, the Netherlands
| | | | | | - Lennie P G Derde
- University Medical Center Utrecht, Department of Intensive Care Medicine, Utrecht, the Netherlands
| | - Jaap Ten Oever
- Radboud university medical center, Radboud Center for Infectious Diseases (RCI), Nijmegen, the Netherlands; Radboud university medical center, Department of Internal Medicine, Nijmegen, the Netherlands
| | - Heiman F L Wertheim
- Radboud university medical center, Radboud Center for Infectious Diseases (RCI), Nijmegen, the Netherlands; Radboud university medical center, Department of Medical Microbiology, Nijmegen, the Netherlands
| | - Marlies E J L Hulscher
- Radboud university medical center, Scientific Center for Quality of Healthcare (IQ healthcare), Nijmegen, the Netherlands; Radboud university medical center, Radboud Center for Infectious Diseases (RCI), Nijmegen, the Netherlands
| | - Jeroen A Schouten
- Radboud university medical center, Department of Intensive Care Medicine, Nijmegen, the Netherlands; Radboud university medical center, Scientific Center for Quality of Healthcare (IQ healthcare), Nijmegen, the Netherlands; Radboud university medical center, Radboud Center for Infectious Diseases (RCI), Nijmegen, the Netherlands
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6
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Cartuliares MB, Søgaard SN, Rosenvinge FS, Mogensen CB, Hertz MA, Skjøt-Arkil H. Antibiotic Guideline Adherence at the Emergency Department: A Descriptive Study from a Country with a Restrictive Antibiotic Policy. Antibiotics (Basel) 2023; 12:1680. [PMID: 38136712 PMCID: PMC10740443 DOI: 10.3390/antibiotics12121680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 11/16/2023] [Accepted: 11/24/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND Denmark has a low level of antimicrobial resistance (AMR). Patients hospitalized with suspected infection often present with unspecific symptoms. This challenges the physician between using narrow-spectrum antibiotics in accordance with guidelines or broad-spectrum antibiotics to compensate for diagnostic uncertainty. The aim of this study was to investigate adherence to a restrictive antibiotic guideline for the most common infection in emergency departments (EDs), namely community-acquired pneumonia (CAP). METHOD This multicenter descriptive cross-sectional study included adults admitted to Danish EDs with a suspected infection. Data were collected prospectively from medical records. RESULTS We included 954 patients in the analysis. The most prescribed antibiotics were penicillin with beta-lactamase inhibitor at 4 h (307 (32.2%)), 48 h (289 (30.3%)), and day 5 after admission (218 (22.9%)). The empirical antibiotic treatment guidelines for CAP were followed for 126 (31.3%) of the CAP patients. At 4 h, antibiotics were administered intravenously to 244 (60.7%) of the CAP patients. At day 5, 218 (54.4%) received oral antibiotics. CONCLUSION Adherence to CAP guidelines was poor. In a country with a restrictive antibiotic policy, infections are commonly treated with broad-spectrum antibiotics against recommendations.
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Affiliation(s)
- Mariana B. Cartuliares
- Department of Emergency Medicine, University Hospital of Southern Denmark, 6200 Aabenraa, Denmark; (M.B.C.)
- Department of Regional Health Research, University of Southern Denmark, 6200 Aabenraa, Denmark
| | - Sara N. Søgaard
- Department of Emergency Medicine, University Hospital of Southern Denmark, 6200 Aabenraa, Denmark; (M.B.C.)
- Department of Regional Health Research, University of Southern Denmark, 6200 Aabenraa, Denmark
| | - Flemming S. Rosenvinge
- Department of Clinical Microbiology, Odense University Hospital, 5000 Odense, Denmark
- Research Unit of Clinical Microbiology, Department of Clinical Research, University of Southern Denmark, 5000 Odense, Denmark
| | - Christian B. Mogensen
- Department of Emergency Medicine, University Hospital of Southern Denmark, 6200 Aabenraa, Denmark; (M.B.C.)
- Department of Regional Health Research, University of Southern Denmark, 6200 Aabenraa, Denmark
| | - Mathias Amdi Hertz
- Department of Infectious Diseases, Odense University Hospital, University of Southern Denmark, 5000 Odense, Denmark
- Research Unit of Infectious Diseases, Department of Clinical Research, University of Southern, 5000 Odense, Denmark
| | - Helene Skjøt-Arkil
- Department of Emergency Medicine, University Hospital of Southern Denmark, 6200 Aabenraa, Denmark; (M.B.C.)
- Department of Regional Health Research, University of Southern Denmark, 6200 Aabenraa, Denmark
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Singh S, Nurek M, Mason S, Moore LS, Mughal N, Vizcaychipi MP. WHY STOP? A prospective observational vignette-based study to determine the cognitive-behavioural effects of rapid diagnostic PCR-based point-of-care test results on antibiotic cessation in ICU infections. BMJ Open 2023; 13:e073577. [PMID: 37989388 PMCID: PMC10668237 DOI: 10.1136/bmjopen-2023-073577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 10/19/2023] [Indexed: 11/23/2023] Open
Abstract
OBJECTIVES Point-of-care tests (POCTs) for infection offer accurate rapid diagnostics but do not consistently improve antibiotic stewardship (ASP) of suspected ventilator-associated pneumonia. We aimed to measure the effect of a negative PCR-POCT result on intensive care unit (ICU) clinicians' antibiotic decisions and the additional effects of patient trajectory and cognitive-behavioural factors (clinician intuition, dis/interest in POCT, risk averseness). DESIGN Observational cohort simulation study. SETTING ICU. PARTICIPANTS 70 ICU consultants/trainees working in UK-based teaching hospitals. METHODS Clinicians saw four case vignettes describing patients who had completed a course of antibiotics for respiratory infection. Vignettes comprised clinical and biological data (ie, white cell count, C reactive protein), varied to create four trajectories: clinico-biological improvement (the 'improvement' case), clinico-biological worsening ('worsening'), clinical improvement/biological worsening ('discordant clin better'), clinical worsening/biological improvement ('discordant clin worse'). Based on this, clinicians made an initial antibiotics decision (stop/continue) and rated confidence (6-point Likert scale). A PCR-based POCT was then offered, which clinicians could accept or decline. All clinicians (including those who declined) were shown the result, which was negative. Clinicians updated their antibiotics decision and confidence. MEASURES Antibiotics decisions and confidence were compared pre-POCT versus post-POCT, per vignette. RESULTS A negative POCT result increased the proportion of stop decisions (54% pre-POCT vs 70% post-POCT, χ2(1)=25.82, p<0.001, w=0.32) in all vignettes except improvement (already high), most notably in discordant clin worse (49% pre-POCT vs 74% post-POCT). In a linear regression, factors that significantly reduced clinicians' inclination to stop antibiotics were a worsening trajectory (b=-0.73 (-1.33, -0.14), p=0.015), initial confidence in continuing (b=0.66 (0.56, 0.76), p<0.001) and involuntary receipt of POCT results (clinicians who accepted the POCT were more inclined to stop than clinicians who declined it, b=1.30 (0.58, 2.02), p<0.001). Clinician risk averseness was not found to influence antibiotic decisions (b=-0.01 (-0.12, 0.10), p=0.872). CONCLUSIONS A negative PCR-POCT result can encourage antibiotic cessation in ICU, notably in cases of clinical worsening (where the inclination might otherwise be to continue). This effect may be reduced by high clinician confidence to continue and/or disinterest in POCT, perhaps due to low trust/perceived utility. Such cognitive-behavioural and trajectorial factors warrant greater consideration in future ASP study design.
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Affiliation(s)
- Suveer Singh
- Faculty of Medicine, Imperial College London, London, UK
- Respiratory and Intensive Care Medicine, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Martine Nurek
- Surgery and Cancer, Imperial College London, London, UK
| | - Sonia Mason
- Guy's and St Thomas' Hospitals NHS Trust, London, UK
| | - Luke Sp Moore
- Imperial College London, London, UK
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Nabeela Mughal
- Imperial College London, London, UK
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Marcela P Vizcaychipi
- APMIC, Imperial College London, London, UK
- Magill Department of Anaesthesia and Intensive Care Medicine, Chelsea and Westminster Healthcare NHS Trust, London, UK
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Diggs DT, Tribble AC, Same RG, Newland JG, Lee BR. Appropriateness of antibiotic prescribing varies by clinical services at United States children's hospitals. Infect Control Hosp Epidemiol 2023; 44:1711-1717. [PMID: 37905378 PMCID: PMC10665883 DOI: 10.1017/ice.2023.56] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 02/23/2023] [Accepted: 02/24/2023] [Indexed: 11/02/2023]
Abstract
OBJECTIVE To describe patterns of inappropriate antibiotic prescribing at US children's hospitals and how these patterns vary by clinical service. DESIGN Serial, cross-sectional study using quarterly surveys. SETTING Surveys were completed in quarter 1 2019-quarter 3 2020 across 28 children's hospitals in the United States. PARTICIPANTS Patients at children's hospitals with ≥1 antibiotic order at 8:00 a.m. on institution-selected quarterly survey days. METHODS Antimicrobial stewardship physicians and pharmacists collected data on antibiotic orders and evaluated appropriateness of prescribing. The primary outcome was percentage of inappropriate antibiotics, stratified by clinical service and antibiotic class. Secondary outcomes included reasons for inappropriate use and association of infectious diseases (ID) consultation with appropriateness. RESULTS Of 13,344 orders, 1,847 (13.8%) were inappropriate; 17.5% of patients receiving antibiotics had ≥1 inappropriate order. Pediatric intensive care units (PICU) and hospitalists contributed the most inappropriate orders (n = 384 and n = 314, respectively). Surgical subspecialists had the highest percentage of inappropriate orders (22.5%), and 56.8% of these were for prolonged or unnecessary surgical prophylaxis. ID consultation in the previous 7 days was associated with fewer inappropriate orders (15% vs 10%; P < .001); this association was most pronounced for hospitalist, PICU, and surgical and medical subspecialty services. CONCLUSIONS Inappropriate antibiotic use for hospitalized children persists and varies by clinical service. Across 28 children's hospitals, PICUs and hospitalists contributed the most inappropriate antibiotic orders, and surgical subspecialists' orders were most often judged inappropriate. Understanding service-specific prescribing patterns will enable antimicrobial stewardship programs to better design interventions to optimize antibiotic use.
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Affiliation(s)
- Devin T. Diggs
- College of Science, University of Notre Dame, Notre Dame, Indiana
| | - Alison C. Tribble
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Rebecca G. Same
- Division of Infectious Diseases, Department of Pediatrics, Children’s Hospital of Philadelphia
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jason G. Newland
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri
| | - Brian R. Lee
- Division of Health Services and Outcomes Research, Department of Pediatrics, Children’s Mercy Kansas City, Kansas City, Missouri
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Clark JA, Conway Morris A, Kanaris C, Inwald D, Butt W, Osowicki J, Schlapbach LJ, Curran MD, White D, Daubney E, Agrawal S, Navapurkar V, Török ME, Baker S, Pathan N. A qualitative investigation of paediatric intensive care staff attitudes towards the diagnosis of lower respiratory tract infection in the molecular diagnostics era. INTENSIVE CARE MEDICINE. PAEDIATRIC AND NEONATAL 2023; 1:10. [PMID: 37425493 PMCID: PMC10329081 DOI: 10.1007/s44253-023-00008-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 06/09/2023] [Indexed: 07/11/2023]
Abstract
Background In the past decade, molecular diagnostic syndromic arrays incorporating a range of bacterial and viral pathogens have been described. It is unclear how paediatric intensive care unit (PICU) staff diagnose lower respiratory tract infection (LRTI) and integrate diagnostic array results into antimicrobial decision-making. Methods An online survey with eleven questions was distributed throughout paediatric intensive care societies in the UK, continental Europe and Australasia with a total of 755 members. Participants were asked to rate the clinical factors and investigations they used when prescribing for LRTI. Semi-structured interviews were undertaken with staff who participated in a single-centre observational study of a 52-pathogen diagnostic array. Results Seventy-two survey responses were received; most responses were from senior doctors. Whilst diagnostic arrays were used less frequently than routine investigations (i.e. microbiological culture), they were of comparable perceived utility when making antimicrobial decisions. Prescribers reported that for arrays to be clinically impactful, they would need to deliver results within 6 h for stable patients and within 1 h for unstable patients to inform their immediate decision to prescribe antimicrobials. From 16 staff interviews, we identified that arrays were helpful for the diagnosis and screening of bacterial LRTI. Staff reported it could be challenging to interpret results in some cases due to the high sensitivity of the test. Therefore, results were considered within the context of the patient and discussed within the multidisciplinary team. Conclusions Diagnostic arrays were considered of comparable value to microbiological investigations by PICU prescribers. Our findings support the need for further clinical and economic evaluation of diagnostic arrays in a randomised control trial. Trial registration Clinicaltrials.gov, NCT04233268. Registered on 18 January 2020. Supplementary Information The online version contains supplementary material available at 10.1007/s44253-023-00008-z.
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Affiliation(s)
- John A. Clark
- Department of Paediatrics, University of Cambridge, Level 8, Addenbrooke’s Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ UK
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Andrew Conway Morris
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK
- Division of Immunology, Department of Pathology, University of Cambridge, Cambridge, UK
| | - Constantinos Kanaris
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Blizard Institute, Queen Mary University of London, London, UK
| | - David Inwald
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Warwick Butt
- Paediatric Intensive Care Unit, Royal Children’s Hospital Melbourne, Melbourne, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Australia
| | - Joshua Osowicki
- Infectious Diseases Unit, Department of General Medicine, Royal Children’s Hospital Melbourne, Parkville, Australia
| | - Luregn J. Schlapbach
- Department of Intensive Care and Neonatology and Children’s Research Center, University Children’s Hospital Zürich, Zurich, Switzerland
| | - Martin D. Curran
- United Kingdom Health Security Agency, Clinical Microbiology and Public Health Laboratory, Cambridge, UK
| | - Deborah White
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Esther Daubney
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Shruti Agrawal
- Department of Paediatrics, University of Cambridge, Level 8, Addenbrooke’s Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ UK
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Vilas Navapurkar
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - M. Estée Török
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Division of Infectious Diseases, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Stephen Baker
- Cambridge Institute of Therapeutic Immunology and Infectious Disease, University of Cambridge, Cambridge, UK
| | - Nazima Pathan
- Department of Paediatrics, University of Cambridge, Level 8, Addenbrooke’s Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ UK
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Shen L, Wang T, Yin J, Sun Q, Dyar OJ. Clinical Uncertainty Influences Antibiotic Prescribing for Upper Respiratory Tract Infections: A Qualitative Study of Township Hospital Physicians and Village Doctors in Rural Shandong Province, China. Antibiotics (Basel) 2023; 12:1027. [PMID: 37370346 DOI: 10.3390/antibiotics12061027] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/21/2023] [Accepted: 06/06/2023] [Indexed: 06/29/2023] Open
Abstract
OBJECTIVE This study aimed to explore how clinical uncertainty influences antibiotic prescribing practices among township hospital physicians and village doctors in rural Shandong Province, China. METHODS Qualitative semi-structured interviews were conducted with 30 township hospital physicians and 6 village doctors from rural Shandong Province, China. A multi-stage random sampling method was used to identify respondents. Conceptual content analysis together with Colaizzi's method were used to generate qualitative codes and identify themes. RESULTS Three final thematic categories emerged during the data analysis: (1) Incidence and treatment of Upper Respiratory Tract Infections (URTIs) in township hospitals and village clinics; (2) Antibiotic prescribing practices based on the clinical experience of clinicians; (3) Influence of clinical uncertainty on antibiotic prescribing. Respondents from both township hospitals and village clinics reported that URTIs were the most common reason for antibiotic prescriptions at their facilities and that clinical uncertainty appears to be an important driver for the overuse of antibiotics for URTIs. Clinical uncertainty was primarily due to: (1) Diagnostic uncertainty (establishing a relevant diagnosis is hindered by limited diagnostic resources and capacities, as well as limited willingness of patients to pay for investigations), and (2) Insufficient prognostic evidence. As a consequence of the clinical uncertainty caused by both diagnostic and prognostic uncertainty, respondents stated that antibiotics are frequently prescribed for URTIs to prevent both prolonged courses or recurrence of the disease, as well as clinical worsening, hospital admission, or complications. CONCLUSION Our study suggests that clinical uncertainty is a key driver for the overuse and misuse of prescribing antibiotics for URTIs in both rural township hospitals and village clinics in Shandong province, China, and that interventions to reduce clinical uncertainty may help minimize the unnecessary use of antibiotics in these settings. Interventions that use clinical rules to identify patients at low risk of complications or hospitalization may be more feasible in the near-future than laboratory-based interventions aimed at reducing diagnostic uncertainty.
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Affiliation(s)
- Liyan Shen
- Center for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan 250012, China
- NHC Key Lab of Health Economics and Policy Research (Shandong University), Jinan 250012, China
| | - Ting Wang
- Center for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan 250012, China
- NHC Key Lab of Health Economics and Policy Research (Shandong University), Jinan 250012, China
| | - Jia Yin
- Center for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan 250012, China
- NHC Key Lab of Health Economics and Policy Research (Shandong University), Jinan 250012, China
| | - Qiang Sun
- Center for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan 250012, China
- NHC Key Lab of Health Economics and Policy Research (Shandong University), Jinan 250012, China
| | - Oliver James Dyar
- Department of Public Health and Caring Sciences, Uppsala University, 75122 Uppsala, Sweden
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11
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Poluektova O, Robertson DA, Rafferty A, Cunney R, Lunn PD. A scoping review and behavioural analysis of factors underlying overuse of antimicrobials. JAC Antimicrob Resist 2023; 5:dlad043. [PMID: 37168837 PMCID: PMC10164659 DOI: 10.1093/jacamr/dlad043] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 03/14/2023] [Indexed: 05/13/2023] Open
Abstract
Background Overuse of antimicrobials is a challenging global issue that contributes to antimicrobial resistance. Despite widespread awareness of the problem among members of the medical community and various attempts to improve prescription practices, existing antimicrobial stewardship programmes are not always effective. In our view, this may reflect limited understanding of factors that influence prescription of antimicrobials as empirical therapy, implying a need to address the psychological mechanisms behind some of the specific behaviours involved. Objectives To identify factors that influence the antimicrobials prescription as empirical therapy, and to relate these factors to findings from behavioural science. Methods We conducted a scoping review of the literature on the factors underlying antimicrobial prescription decisions, following the protocol designed using PRISMA guidelines. Results and conclusions From a final sample of 90 sources, we identified ten factors important in antimicrobial prescription decisions. In the second stage of our analysis, we grouped them into five final categories: (1) nature of the decision, (2) social influences, (3) individual differences, (4) characteristics of the patient, (5) context. We analyse these categories using a behavioural science perspective.
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Affiliation(s)
| | - Deirdre A Robertson
- Behavioural Research Unit, The Economic and Social Research Institute, Whitaker Square, Sir John Rogerson’s Quay, Ireland
- Trinity College Dublin, School of Psychology, Dublin, Ireland
| | - Aisling Rafferty
- Children’s Health Ireland, Department of Pharmacy, Dublin, Ireland
- University of Birmingham, School of Pharmacy, Institute of Clinical Sciences,Birmingham, UK
| | - Robert Cunney
- Children’s Health Ireland, Irish Meningitis and Sepsis Reference Laboratory, Dublin, Ireland
- Royal College of Surgeons in Ireland, Department of Microbiology, Dublin, Ireland
- Children’s Health Ireland, Department of Microbiology, Dublin, Ireland
| | - Peter D Lunn
- Behavioural Research Unit, The Economic and Social Research Institute, Whitaker Square, Sir John Rogerson’s Quay, Ireland
- Trinity College Dublin, Department of Economics, Dublin, Ireland
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12
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Baghdadi JD, Goodman KE, Magder LS, Heil EL, Claeys K, Bork J, Harris AD. Clinical, contextual and hospital-level factors associated with escalation and de-escalation of empiric Gram-negative antibiotics among US inpatients. JAC Antimicrob Resist 2023; 5:dlad054. [PMID: 37193004 PMCID: PMC10182731 DOI: 10.1093/jacamr/dlad054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 04/19/2023] [Indexed: 05/18/2023] Open
Abstract
Background Empiric Gram-negative antibiotics are frequently changed in response to new information. To inform antibiotic stewardship, we sought to identify predictors of antibiotic changes using information knowable before microbiological test results. Methods We performed a retrospective cohort study. Survival-time models were used to evaluate clinical factors associated with antibiotic escalation and de-escalation (defined as an increase or decrease, respectively, in the spectrum or number of Gram-negative antibiotics within 5 days of initiation). Spectrum was categorized as narrow, broad, extended or protected. Tjur's D statistic was used to estimate the discriminatory power of groups of variables. Results In 2019, 2 751 969 patients received empiric Gram-negative antibiotics at 920 study hospitals. Antibiotic escalation occurred in 6.5%, and 49.2% underwent de-escalation; 8.8% were changed to an equivalent regimen. Escalation was more likely when empiric antibiotics were narrow-spectrum (HR 19.0 relative to protected; 95% CI: 17.9-20.1), broad-spectrum (HR 10.3; 95% CI: 9.78-10.9) or extended-spectrum (HR 3.49; 95% CI: 3.30-3.69). Patients with sepsis present on admission (HR 1.94; 95% CI: 1.91-1.96) and urinary tract infection present on admission (HR 1.36; 95% CI: 1.35-1.38) were more likely to undergo antibiotic escalation than patients without these syndromes. De-escalation was more likely with combination therapy (HR 2.62 per additional agent; 95% CI: 2.61-2.63) or narrow-spectrum empiric antibiotics (HR 1.67 relative to protected; 95% CI: 1.65-1.69). Choice of empiric regimen accounted for 51% and 74% of the explained variation in antibiotic escalation and de-escalation, respectively. Conclusions Empiric Gram-negative antibiotics are frequently de-escalated early in hospitalization, whereas escalation is infrequent. Changes are primarily driven by choice of empiric therapy and presence of infectious syndromes.
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Affiliation(s)
- Jonathan D Baghdadi
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Katherine E Goodman
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Laurence S Magder
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Emily L Heil
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Kimberly Claeys
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Jacqueline Bork
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Anthony D Harris
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
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13
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Owens R, Bamford K, Pinion S, Garry E, Cranmer E, Pearce C, Wint HH, Gill S, Philips R, Khan A, Roy Bentley S, Roberts N, Keating B, Askaroff N, Morphew M, Orr C, Mouket T, Pope K, Powell N. Assessment of the appropriateness of antibiotic prescribing in an acute UK hospital using a national audit tool: a single centre retrospective survey. Eur J Hosp Pharm 2023:ejhpharm-2022-003569. [PMID: 37117009 DOI: 10.1136/ejhpharm-2022-003569] [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: 10/04/2022] [Accepted: 03/28/2023] [Indexed: 04/30/2023] Open
Abstract
INTRODUCTION Antibiotic use drives antibiotic resistance. The UK antimicrobial resistance (AMR) strategy aims to reduce antibiotic use. We aimed to quantify excess antibiotic use in a district general hospital in south-west England. METHODS Medical patients discharged in August 2020 who had received antibiotics were included. An audit tool of antibiotic prescribing appropriateness was used to collect relevant clinical information regarding each patient case. The appropriateness of antibiotic use was then determined by two infection specialists and excess days of therapy (DOTs) calculated. RESULTS 647 patients were discharged in August 2020. Of the 1658 antibiotic DOTs for the 184 patients reviewed, 403 (24%) were excess DOTs. The excess antibiotic DOTs were prescribed in 92 patients (50%); 112/403 (27.8%) excess DOTs originated at the initiation of antibiotic therapy (time point A); 184/403 (45.7%) of excess DOTs occurred at the antibiotic review pre-72 hours (time point B); and 107/403 (26.6%) of excess DOTs were due to protracted antibiotic courses (time point C). CONCLUSION 24% of antibiotic DOTs were deemed unnecessary. The greatest opportunity to reduce antibiotic use safely was the pre-72 hours antibiotic review, which may provide a target for reducing excess antimicrobial therapy in line with the national AMR strategy.
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Affiliation(s)
- Rhys Owens
- Emergency Department, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Kathy Bamford
- Medical Microbiology, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Sophie Pinion
- Anaesthetics, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Emma Garry
- Department of Obstetrics and Gynaecology, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Emily Cranmer
- Eldercare, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Catharine Pearce
- Respiratory department, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Htet Htet Wint
- Neurology department, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Simon Gill
- Respiratory department, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Ryan Philips
- Acute Medicine, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Adnan Khan
- Eldercare, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Selina Roy Bentley
- Enhanced Perioperative Care Unit, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Neil Roberts
- University Hositals Plymouth NHS Trust, Plymouth, UK
| | | | - Natasha Askaroff
- Oncology Department, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Megan Morphew
- Oncology, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Charles Orr
- Emergency Department, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Tarek Mouket
- Acute Medicine, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Katherine Pope
- Acute Medicine, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Neil Powell
- Pharmacy Department, Royal Cornwall Hospital NHS Trust, Cornwall, UK
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14
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Abstract
PURPOSE OF REVIEW The coronavirus disease 2019 pandemic demonstrated broad utility of pathogen sequencing with rapid methodological progress alongside global distribution of sequencing infrastructure. This review considers implications for now moving clinical metagenomics into routine service, with respiratory metagenomics as the exemplar use-case. RECENT FINDINGS Respiratory metagenomic workflows have completed proof-of-concept, providing organism identification and many genotypic antimicrobial resistance determinants from clinical samples in <6 h. This enables rapid escalation or de-escalation of empiric therapy for patient benefit and reducing selection of antimicrobial resistance, with genomic-typing available in the same time-frame. Attention is now focussed on demonstrating clinical, health-economic, accreditation, and regulatory requirements. More fundamentally, pathogen sequencing challenges the traditional culture-orientated time frame of microbiology laboratories, which through automation and centralisation risks becoming increasingly separated from the clinical setting. It presents an alternative future where infection experts are brought together around a single genetic output in an acute timeframe, aligning the microbiology target operating model with the wider human genomic and digital strategy. SUMMARY Pathogen sequencing is a transformational proposition for microbiology laboratories and their infectious diseases, infection control, and public health partners. Healthcare systems that link output from routine clinical metagenomic sequencing, with pandemic and antimicrobial resistance surveillance, will create valuable tools for protecting their population against future infectious diseases threats.
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Affiliation(s)
- Jonathan D Edgeworth
- Department of Infectious Diseases, Guy's & St Thomas' NHS Foundation Trust & Department of Infectious Diseases, Kings College London, UK
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15
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Scarborough RO, Sri AE, Browning GF, Hardefeldt LY, Bailey KE. ‘Brave Enough’: A Qualitative Study of Veterinary Decisions to Withhold or Delay Antimicrobial Treatment in Pets. Antibiotics (Basel) 2023; 12:antibiotics12030540. [PMID: 36978407 PMCID: PMC10044613 DOI: 10.3390/antibiotics12030540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 02/24/2023] [Accepted: 02/27/2023] [Indexed: 03/11/2023] Open
Abstract
Veterinarians sometimes prescribe antimicrobials even when they know or suspect that they are unnecessary. The drivers of this behaviour must be understood to design effective antimicrobial stewardship interventions. Semi-structured interviews were conducted with 22 veterinarians who treated companion animals in Australia. The Theory of Planned Behaviour was used to organise interview themes, focusing on a decision to withhold antimicrobial therapy in the absence of a clear indication. Many background factors influenced antimicrobial-withholding decisions, including the veterinarian’s communication skills, general attitudes towards antimicrobial resistance (AMR), habits and energy levels. Client awareness of AMR and the veterinarian–client relationship were also important. Beliefs about the consequences of withholding antimicrobials (behavioural beliefs) were dominated by fears of the animal’s condition deteriorating and of failing to meet client expectations. These fears, weighed against the seemingly distant consequences of AMR, were major barriers to withholding antimicrobials. Normative beliefs were primarily focused on the expected approval (or disapproval) of the client and of other veterinarians. Control beliefs about the difficulty of withholding antimicrobials centred around client factors, most importantly, their capacity to adequately monitor their animal, to pay for further investigations, or to undertake non-antimicrobial management, such as wound care, at home. The use of antimicrobials by companion animal veterinarians in the absence of a clear indication is often powerfully driven by behavioural beliefs, chiefly, fears of clinical deterioration and of failing to meet client expectations.
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Affiliation(s)
- Ri O. Scarborough
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, University of Melbourne, Parkville, VIC 3010, Australia
- National Centre for Antimicrobial Stewardship, Peter Doherty Institute, Parkville, VIC 3052, Australia
- Correspondence:
| | - Anna E. Sri
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, University of Melbourne, Parkville, VIC 3010, Australia
- National Centre for Antimicrobial Stewardship, Peter Doherty Institute, Parkville, VIC 3052, Australia
| | - Glenn F. Browning
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, University of Melbourne, Parkville, VIC 3010, Australia
- National Centre for Antimicrobial Stewardship, Peter Doherty Institute, Parkville, VIC 3052, Australia
| | - Laura Y. Hardefeldt
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, University of Melbourne, Parkville, VIC 3010, Australia
- National Centre for Antimicrobial Stewardship, Peter Doherty Institute, Parkville, VIC 3052, Australia
| | - Kirsten E. Bailey
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, University of Melbourne, Parkville, VIC 3010, Australia
- National Centre for Antimicrobial Stewardship, Peter Doherty Institute, Parkville, VIC 3052, Australia
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16
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Mixed-methods process evaluation of a respiratory-culture diagnostic stewardship intervention. Infect Control Hosp Epidemiol 2023; 44:191-199. [PMID: 36594433 DOI: 10.1017/ice.2022.299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To conduct a process evaluation of a respiratory culture diagnostic stewardship intervention. DESIGN Mixed-methods study. SETTING Tertiary-care pediatric intensive care unit (PICU). PARTICIPANTS Critical care, infectious diseases, and pulmonary attending physicians and fellows; PICU nurse practitioners and hospitalist physicians; pediatric residents; and PICU nurses and respiratory therapists. METHODS This mixed-methods study was conducted concurrently with a diagnostic stewardship intervention to reduce the inappropriate collection of respiratory cultures in mechanically ventilated children. We quantified baseline respiratory culture utilization and indications for ordering using quantitative methods. Semistructured interviews informed by these data and the Consolidated Framework for Implementation Research (CFIR) were then performed, recorded, transcribed, and coded to identify salient themes. Finally, themes identified in these interviews were used to create a cross-sectional survey. RESULTS The number of cultures collected per day of service varied between attending physicians (range, 2.2-27 cultures per 100 days). In total, 14 interviews were performed, and 87 clinicians completed the survey (response rate, 47%) and 77 nurses or respiratory therapists completed the survey (response rate, 17%). Clinicians varied in their stated practices regarding culture ordering, and these differences both clustered by specialty and were associated with perceived utility of the respiratory culture. Furthermore, group "default" practices, fear, and hierarchy were drivers of culture orders. Barriers to standardization included fear of a missed diagnosis and tension between practice standardization and individual decision making. CONCLUSIONS We identified significant variation in utilization and perceptions of respiratory cultures as well as several key barriers to implementation of this diagnostic test stewardship intervention.
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17
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Clark JA, Conway Morris A, Curran MD, White D, Daubney E, Kean IRL, Navapurkar V, Bartholdson Scott J, Maes M, Bousfield R, Török ME, Inwald D, Zhang Z, Agrawal S, Kanaris C, Khokhar F, Gouliouris T, Baker S, Pathan N. The rapid detection of respiratory pathogens in critically ill children. Crit Care 2023; 27:11. [PMID: 36627688 PMCID: PMC9831374 DOI: 10.1186/s13054-023-04303-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 01/06/2023] [Indexed: 01/12/2023] Open
Abstract
PURPOSE Respiratory infections are the most common reason for admission to paediatric intensive care units (PICU). Most patients with lower respiratory tract infection (LRTI) receive broad-spectrum antimicrobials, despite low rates of bacterial culture confirmation. Here, we evaluated a molecular diagnostic test for LRTI to inform the better use of antimicrobials. METHODS The Rapid Assay for Sick Children with Acute Lung infection Study was a single-centre, prospective, observational cohort study of mechanically ventilated children (> 37/40 weeks corrected gestation to 18 years) with suspected community acquired or ventilator-associated LRTI. We evaluated the use of a 52-pathogen custom TaqMan Array Card (TAC) to identify pathogens in non-bronchoscopic bronchoalveolar lavage (mini-BAL) samples. TAC results were compared to routine microbiology testing. Primary study outcomes were sensitivity and specificity of TAC, and time to result. RESULTS We enrolled 100 patients, all of whom were tested with TAC and 91 of whom had matching culture samples. TAC had a sensitivity of 89.5% (95% confidence interval (CI95) 66.9-98.7) and specificity of 97.9% (CI95 97.2-98.5) compared to routine bacterial and fungal culture. TAC took a median 25.8 h (IQR 9.1-29.8 h) from sample collection to result. Culture was significantly slower: median 110.4 h (IQR 85.2-141.6 h) for a positive result and median 69.4 h (IQR 52.8-78.6) for a negative result. CONCLUSIONS TAC is a reliable and rapid adjunct diagnostic approach for LRTI in critically ill children, with the potential to aid early rationalisation of antimicrobial therapy.
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Affiliation(s)
- John A Clark
- Department of Paediatrics, Addenbrooke's Hospital, University of Cambridge, Level 8, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK. .,Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
| | - Andrew Conway Morris
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.,Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK.,Division of Immunology, Department of Pathology, University of Cambridge, Cambridge, UK
| | - Martin D Curran
- Clinical Microbiology and Public Health Laboratory, United Kingdom Health Security Agency, Cambridge, UK
| | - Deborah White
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Esther Daubney
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Iain R L Kean
- Department of Paediatrics, Addenbrooke's Hospital, University of Cambridge, Level 8, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - Vilas Navapurkar
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Josefin Bartholdson Scott
- Cambridge Institute of Therapeutic Immunology and Infectious Disease, University of Cambridge, Cambridge, UK
| | - Mailis Maes
- Cambridge Institute of Therapeutic Immunology and Infectious Disease, University of Cambridge, Cambridge, UK
| | - Rachel Bousfield
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.,Clinical Microbiology and Public Health Laboratory, United Kingdom Health Security Agency, Cambridge, UK
| | - M Estée Török
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.,Division of Infectious Diseases, Department of Medicine, University of Cambridge, Cambridge, UK
| | - David Inwald
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Zhenguang Zhang
- Department of Paediatrics, Addenbrooke's Hospital, University of Cambridge, Level 8, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - Shruti Agrawal
- Department of Paediatrics, Addenbrooke's Hospital, University of Cambridge, Level 8, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK.,Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Constantinos Kanaris
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.,Blizard Institute, Queen Mary University of London, London, UK
| | - Fahad Khokhar
- Cambridge Institute of Therapeutic Immunology and Infectious Disease, University of Cambridge, Cambridge, UK
| | - Theodore Gouliouris
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.,Clinical Microbiology and Public Health Laboratory, United Kingdom Health Security Agency, Cambridge, UK
| | - Stephen Baker
- Cambridge Institute of Therapeutic Immunology and Infectious Disease, University of Cambridge, Cambridge, UK
| | - Nazima Pathan
- Department of Paediatrics, Addenbrooke's Hospital, University of Cambridge, Level 8, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK.,Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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18
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Bolton WJ, Rawson TM, Hernandez B, Wilson R, Antcliffe D, Georgiou P, Holmes AH. Machine learning and synthetic outcome estimation for individualised antimicrobial cessation. Front Digit Health 2022; 4:997219. [PMID: 36479189 PMCID: PMC9719971 DOI: 10.3389/fdgth.2022.997219] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 10/27/2022] [Indexed: 08/18/2023] Open
Abstract
The decision on when it is appropriate to stop antimicrobial treatment in an individual patient is complex and under-researched. Ceasing too early can drive treatment failure, while excessive treatment risks adverse events. Under- and over-treatment can promote the development of antimicrobial resistance (AMR). We extracted routinely collected electronic health record data from the MIMIC-IV database for 18,988 patients (22,845 unique stays) who received intravenous antibiotic treatment during an intensive care unit (ICU) admission. A model was developed that utilises a recurrent neural network autoencoder and a synthetic control-based approach to estimate patients' ICU length of stay (LOS) and mortality outcomes for any given day, under the alternative scenarios of if they were to stop vs. continue antibiotic treatment. Control days where our model should reproduce labels demonstrated minimal difference for both stopping and continuing scenarios indicating estimations are reliable (LOS results of 0.24 and 0.42 days mean delta, 1.93 and 3.76 root mean squared error, respectively). Meanwhile, impact days where we assess the potential effect of the unobserved scenario showed that stopping antibiotic therapy earlier had a statistically significant shorter LOS (mean reduction 2.71 days, p -value <0.01). No impact on mortality was observed. In summary, we have developed a model to reliably estimate patient outcomes under the contrasting scenarios of stopping or continuing antibiotic treatment. Retrospective results are in line with previous clinical studies that demonstrate shorter antibiotic treatment durations are often non-inferior. With additional development into a clinical decision support system, this could be used to support individualised antimicrobial cessation decision-making, reduce the excessive use of antibiotics, and address the problem of AMR.
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Affiliation(s)
- William J. Bolton
- Centre for Antimicrobial Optimisation, Imperial College London, London, United Kingdom
- AI4Health Centre for Doctoral Training, Imperial College London, London, United Kingdom
- Department of Computing, Imperial College London, London, United Kingdom
| | - Timothy M. Rawson
- Centre for Antimicrobial Optimisation, Imperial College London, London, United Kingdom
- National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, United Kingdom
| | - Bernard Hernandez
- Centre for Antimicrobial Optimisation, Imperial College London, London, United Kingdom
- Centre for Bio-inspired Technology, Department of Electrical and Electronic Engineering, Imperial College London, London, United Kingdom
| | - Richard Wilson
- Centre for Antimicrobial Optimisation, Imperial College London, London, United Kingdom
- National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, United Kingdom
| | - David Antcliffe
- Department of Critical Care, Imperial College Healthcare NHS Trust, London, United Kingdom
- Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Pantelis Georgiou
- Centre for Antimicrobial Optimisation, Imperial College London, London, United Kingdom
- Centre for Bio-inspired Technology, Department of Electrical and Electronic Engineering, Imperial College London, London, United Kingdom
| | - Alison H. Holmes
- Centre for Antimicrobial Optimisation, Imperial College London, London, United Kingdom
- National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, United Kingdom
- Department of Infectious Diseases, Imperial College London, London, United Kingdom
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19
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SHEA statement on antibiotic stewardship in hospitals during public health emergencies. Infect Control Hosp Epidemiol 2022; 43:1541-1552. [PMID: 36102000 PMCID: PMC9672827 DOI: 10.1017/ice.2022.194] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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20
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Lanckohr C, Bracht H. Antimicrobial stewardship. Curr Opin Crit Care 2022; 28:551-556. [PMID: 35942707 DOI: 10.1097/mcc.0000000000000967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The optimal use of antimicrobials is necessary to slow resistance development and improve patient outcomes. Antimicrobial stewardship (AMS) is a bundle of interventions aimed at promoting the responsible use of antiinfectives. The ICU is an important field of activity for AMS because of high rates of antimicrobial use, high prevalence of resistant pathogens and complex pharmacology. This review discusses aims and interventions of AMS with special emphasis on the ICU. RECENT FINDINGS AMS-interventions can improve the quality and quantity of antimicrobial prescribing in the ICU without compromising patient outcomes. The de-escalation of empiric therapy according to microbiology results and the limitation of treatment duration are important steps to reduce resistance pressure. Owing to the complex nature of critical illness, the pharmacological optimization of antimicrobial therapy is an important goal in the ICU. AMS-objectives and strategies are also applicable to patients with sepsis. This is reflected in the most recent guidelines by the Surviving Sepsis Campaign. AMS-interventions need to be adapted to their respective setting and be mindful of local prescribing cultures and prescribers' attitudes. SUMMARY AMS in the ICU is effective and safe. Intensivists should be actively involved in AMS-programs and propagate responsible use of antimicrobials.
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Affiliation(s)
- Christian Lanckohr
- Antibiotic Stewardship Team, Institute of Hygiene, University Hospital Münster, Münster
| | - Hendrik Bracht
- Central Emergency Services, University Hospital Ulm, Ulm, Germany
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21
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Rynkiewich K, Uttla K, Hojat L. Instant Gratification and Overtreating to Be Safe: Perceptions of U.S. Intensive Care Unit Pharmacists and Residents on Antimicrobial Stewardship. Antibiotics (Basel) 2022; 11:antibiotics11091224. [PMID: 36140003 PMCID: PMC9495149 DOI: 10.3390/antibiotics11091224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 08/17/2022] [Accepted: 09/05/2022] [Indexed: 11/16/2022] Open
Abstract
Antimicrobial stewardship programs have been associated with numerous impacts on medical practice including reductions in costs, antimicrobial resistance, and adverse events. While antimicrobial stewardship is now considered an essential element of medical practice, the understandings of the value of antimicrobial stewardship among medical practitioners vary. Additionally, non-physician practitioners are regularly left out of antimicrobial stewardship interventions targeting antimicrobial decision-making. Here, we contribute the perspective from resident physicians and specialists in pharmacy regarding their involvement in antimicrobial prescribing. Notably, our semi-structured interviews with 10 residents and pharmacy specialists described their limited autonomy in the clinical setting. However, the participants regularly worked alongside primary antimicrobial decision-makers and described feeling pressure to overtreat to be safe. The clear rationales and motivations associated with antimicrobial prescribing have a noticeable impact on physicians in training and non-physician practitioners, and as such, we argue that antimicrobial stewardship interventions targeting primary antimicrobial decision-makers are missing an opportunity to address the breadth of antimicrobial prescribing culture. By looking at the perspectives and rationales of physicians in training and non-physician practitioners, we can see evidence that the act of antimicrobial prescribing is impacted by individuals on all levels of the hierarchies present in medical practice.
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Affiliation(s)
- Katharina Rynkiewich
- Department of Anthropology, Florida Atlantic University, Boca Raton, FL 33431, USA
- Correspondence:
| | - Kruthika Uttla
- Department of Anthropology, Case Western Reserve University, Cleveland, OH 44106, USA
| | - Leila Hojat
- Department of Medicine, Division of Infectious Diseases, Case Western Reserve University, Cleveland, OH 44106, USA
- Division of Infectious Diseases and HIV Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
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22
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A limited role for microbiological testing for childhood lower respiratory tract infections in primary care: managing diagnostic uncertainty by withholding antibiotics and watchful waiting. Clin Microbiol Infect 2022; 28:1189-1192. [PMID: 35738322 DOI: 10.1016/j.cmi.2022.06.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 06/10/2022] [Accepted: 06/12/2022] [Indexed: 11/20/2022]
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23
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Fabre V, Cosgrove SE, Secaira C, Tapia Torrez JC, Lessa FC, Patel TS, Quiros R. Antimicrobial stewardship in Latin America: Past, present, and future. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2022; 2:e68. [PMID: 36483374 PMCID: PMC9726506 DOI: 10.1017/ash.2022.47] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 03/16/2022] [Accepted: 03/21/2022] [Indexed: 06/01/2023]
Abstract
Implementation of antimicrobial stewardship programs (ASPs) in well-resourced countries has been associated with reductions in antibiotic-resistant infections and improved patient outcomes. Several guidance documents providing recommendations on how to structure antimicrobial stewardship activities at the national and hospital level in resource-limited settings have been published. However, few hospitals in Latin America report having a structure or resources needed for a successful ASP. Given the alarming increases in antimicrobial resistance in Latin America, better understanding of barriers to promote implementation of effective ASPs is urgently needed. We have summarized past and present antimicrobial stewardship activities in Latin American hospitals, and we describe key elements needed in future efforts to strengthen antimicrobial stewardship in the region.
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Affiliation(s)
- Valeria Fabre
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Sara E. Cosgrove
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | | | | | - Fernanda C. Lessa
- International Infection Control Program, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, United States
| | - Twisha S. Patel
- International Infection Control Program, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, United States
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24
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Cresswell K, Hinder S, Sheikh A, Pontefract S, Watson N, Price D, Heed A, Coleman J, Ennis H, Beggs J, Chuter A, Williams R. ePrescribing-based antimicrobial stewardship practices in an English National Health service hospital: a qualitative interview study (Preprint). JMIR Form Res 2022. [DOI: 10.2196/37863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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25
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Janssen RME, Oerlemans AJM, Van Der Hoeven JG, Ten Oever J, Schouten JA, Hulscher MEJL. OUP accepted manuscript. J Antimicrob Chemother 2022; 77:2105-2119. [PMID: 35612930 PMCID: PMC9333408 DOI: 10.1093/jac/dkac162] [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: 01/17/2022] [Accepted: 05/02/2022] [Indexed: 11/14/2022] Open
Abstract
Background In daily hospital practice, antibiotic therapy is commonly prescribed for longer than recommended in guidelines. Understanding the key drivers of prescribing behaviour is crucial to generate meaningful interventions to bridge this evidence-to-practice gap. Objectives To identify behavioural determinants that might prevent or enable improvements in duration of antibiotic therapy in daily practice. Methods We systematically searched PubMed, Embase, PsycINFO and Web of Science for relevant studies that were published between January 2000 and August 2021. All qualitative, quantitative and mixed-method studies in adults in a hospital setting that reported determinants of antibiotic therapy duration were included. Results Twenty-two papers were included in this review. A first set of studies provided 82 behavioural determinants that shape how health professionals make decisions about duration; most of these were related to individual health professionals’ knowledge, skills and cognitions, and to professionals’ interactions. A second set of studies provided 17 determinants that point to differences in duration regarding various pathogens, diseases, or patient, professional or hospital department characteristics, but do not explain why or how these differences occur. Conclusions Limited literature is available describing a wide range of determinants that influence duration of antibiotic therapy in daily practice. This review provides a stepping stone for the development of stewardship interventions to optimize antibiotic therapy duration, but more research is warranted. Stewardship teams must develop complex improvement interventions to address the wide variety of behavioural determinants, adapted to the specific pathogen, disease, patient, professional and/or hospital department involved.
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Affiliation(s)
| | - Anke J M Oerlemans
- Scientific Center for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Johannes G Van Der Hoeven
- Department of Intensive Care Medicine, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jaap Ten Oever
- Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Internal Medicine, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jeroen A Schouten
- Department of Intensive Care Medicine, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- Scientific Center for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marlies E J L Hulscher
- Scientific Center for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands
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26
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Tarrant C, Krockow EM. Antibiotic overuse: managing uncertainty and mitigating against overtreatment. BMJ Qual Saf 2021; 31:163-167. [PMID: 34285113 DOI: 10.1136/bmjqs-2021-013615] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Carolyn Tarrant
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Eva M Krockow
- Department of Neuroscience, Psychology and Behaviour, University of Leicester, Leicester, UK
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27
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Pandolfo AM, Horne R, Jani Y, Reader TW, Bidad N, Brealey D, Enne VI, Livermore DM, Gant V, Brett SJ. Intensivists' beliefs about rapid multiplex molecular diagnostic testing and its potential role in improving prescribing decisions and antimicrobial stewardship: a qualitative study. Antimicrob Resist Infect Control 2021; 10:95. [PMID: 34187563 PMCID: PMC8243627 DOI: 10.1186/s13756-021-00961-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 06/09/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Rapid molecular diagnostic tests to investigate the microbial aetiology of pneumonias may improve treatment and antimicrobial stewardship in intensive care units (ICUs). Clinicians' endorsement and uptake of these tests is crucial to maximise engagement; however, adoption may be impeded if users harbour unaddressed concerns or if device usage is incompatible with local practice. Accordingly, we strove to identify ICU clinicians' beliefs about molecular diagnostic tests for pneumonias before implementation at the point-of-care. METHODS We conducted semi-structured interviews with 35 critical care doctors working in four ICUs in the United Kingdom. A clinical vignette depicting a fictitious patient with signs of pneumonia was used to explore clinicians' beliefs about the importance of molecular diagnostics and their concerns. Data were analysed thematically. RESULTS Clinicians' beliefs about molecular tests could be grouped into two categories: perceived potential of molecular diagnostics to improve antibiotic prescribing (Molecular Diagnostic Necessity) and concerns about how the test results could be implemented into practice (Molecular Diagnostic Concerns). Molecular Diagnostic Necessity stemmed from beliefs that positive results would facilitate targeted antimicrobial therapy; that negative results would signal the absence of a pathogen, and consequently that having the molecular diagnostic results would bolster clinicians' prescribing confidence. Molecular Diagnostic Concerns included unfamiliarity with the device's capabilities, worry that it would detect non-pathogenic bacteria, uncertainty whether it would fail to detect pathogens, and discomfort with withholding antibiotics until receiving molecular test results. CONCLUSIONS Clinicians believed rapid molecular diagnostics for pneumonias were potentially important and were open to using them; however, they harboured concerns about the tests' capabilities and integration into clinical practice. Implementation strategies should bolster users' necessity beliefs while reducing their concerns; this can be accomplished by publicising the tests' purpose and benefits, identifying and addressing clinicians' misconceptions, establishing a trial period for first-hand familiarisation, and emphasising that, with a swift (e.g., 60-90 min) test, antibiotics can be started and refined after molecular diagnostic results become available.
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Affiliation(s)
- Alyssa M Pandolfo
- Centre for Behavioural Medicine, University College London, British Medical Association House, Tavistock Square, London, WC1H 9JP, UK
| | - Robert Horne
- Centre for Behavioural Medicine, University College London, British Medical Association House, Tavistock Square, London, WC1H 9JP, UK.
| | - Yogini Jani
- UCLH-UCL Centre for Medicines Optimisation Research and Education, University College London Hospitals NHS Foundation Trust, London, UK
| | - Tom W Reader
- Department of Psychological and Behavioural Science, London School of Economics and Political Science, London, UK
| | - Natalie Bidad
- Centre for Behavioural Medicine, University College London, British Medical Association House, Tavistock Square, London, WC1H 9JP, UK
| | - David Brealey
- Division of Critical Care, University College London Hospitals NHS Foundation Trust, London, UK
| | - Virve I Enne
- Division of Infection and Immunity, University College London Faculty of Medical Sciences, London, UK
| | - David M Livermore
- University of East Anglia Norwich Medical School, Norwich, Norfolk, UK
| | - Vanya Gant
- Department of Medical Microbiology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Stephen J Brett
- Department of Surgery and Cancer, Imperial College London, London, UK
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