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Nampoothiri V, Mbamalu O, Mendelson M, Singh S, Charani E. Pharmacist roles in antimicrobial stewardship: a qualitative study from India, South Africa and the United Kingdom. JAC Antimicrob Resist 2024; 6:dlae047. [PMID: 38716399 PMCID: PMC11073750 DOI: 10.1093/jacamr/dlae047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 02/26/2024] [Indexed: 06/29/2024] Open
Abstract
Objective To explore pharmacist roles in antimicrobial stewardship (AMS) in India, South Africa (SA), United Kingdom (UK) and the factors that contribute to their participation in the programme in these countries. Methods Data were collected between April 2019 and March 2022 through semi-structured interviews with key AMS stakeholders from India (Kerala); SA (Western Cape province) and the UK (England). Interviews were conducted face to face or via Zoom and Skype platforms, audio recordings were transcribed verbatim and thematically analysed using a grounded theory approach aided by NVivo 12 software. Results We interviewed 38 key AMS stakeholders (pharmacists and doctors). India and the UK have dedicated AMS pharmacists (Doctor of Pharmacy and Master of Pharmacy graduates with opportunities for additional post-graduate qualifications respectively). Pharmacists in the UK lead AMS programmes, while in India, predominantly in the private sector, pharmacists drive AMS in collaboration with clinicians. In SA, pharmacists (Bachelor of Pharmacy graduates) participate in AMS out of their own commitment in addition to their pharmacy responsibilities. Private sector pharmacists drive AMS while public sector pharmacists participate in clinician-led AMS programmes. Current pharmacy curricula do not provide adequate training in AMS, and this limitation shapes pharmacist roles and acceptance in AMS among clinicians in India and SA. Support of mentors (doctors/senior pharmacists) and self-motivated learning are key factors for effective pharmacist involvement in AMS. Conclusions A contextually developed, standardized and accessible AMS training programme along with pharmacy curricula modification to include AMS, may facilitate prominent pharmacist roles in AMS.
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Affiliation(s)
- Vrinda Nampoothiri
- Department of Health Sciences Research, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Oluchi Mbamalu
- Division of Infectious Diseases & HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Marc Mendelson
- Division of Infectious Diseases & HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Sanjeev Singh
- Department of Medical Administration, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Faridabad, Haryana, India
| | - Esmita Charani
- Division of Infectious Diseases & HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
- Department of Infection Control and Epidemiology, Amrita Institute of Medical Science, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
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Chukwu EE, Abuh D, Idigbe IE, Osuolale KA, Chuka-Ebene V, Awoderu O, Audu RA, Ogunsola FT. Implementation of antimicrobial stewardship programs: A study of prescribers' perspective of facilitators and barriers. PLoS One 2024; 19:e0297472. [PMID: 38241406 PMCID: PMC10798493 DOI: 10.1371/journal.pone.0297472] [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: 09/08/2023] [Accepted: 01/06/2024] [Indexed: 01/21/2024] Open
Abstract
BACKGROUND Despite promising signs of the benefits associated with Antimicrobial Stewardship Programs (ASPs), there remains limited knowledge on how to implement ASPs in peculiar settings for a more elaborate impact. This study explored prescriber experiences and perceptions of the usefulness, and feasibility of strategies employed for the implementation of antimicrobial stewardship (AMS) interventions as well as challenges encountered. METHODS This is a cross-sectional mixed-method survey of prescribers' perspective of the facilitators and barriers of implementing ASP. The quantitative approach comprised of a semi-structured questionnaire and data collected were analyzed using SPSS version 26 while the qualitative approach used focus group discussions followed by content analysis. RESULTS Out of the thirty people that participated in the workshop, twenty-five completed the questionnaires which were analyzed. The respondents included 15 (60.0%) medical doctors and 10 (40.0%) pharmacists. The mean age of the respondents was 36.39±7.23 years with mean year of practice of 9.48±6.01 years. Majority of them (84.0%) were in a position to provide input on the implementation of AMS in their facilities, although their managements had the final decision. The pharmacists (100%) were more likely to agree that antibiotic resistance was a problem for their practice than the medical doctors (78.6%) while equal number (80.0%) of respondents (pharmacists and medical doctors) believed that inappropriate prescribing was a problem. Having a specialized and dedicated team with effective monitoring was recognized as crucial for effective ASP while inadequate personnel was identified as a major barrier. We identified stakeholder's engagement, policies and regulation, as well as education as themes for improving AMS in the country. CONCLUSION The results gave insight into the prescribers' perspective on the facilitators and barriers to antimicrobial stewardship; challenges and possible solutions to implementing ASPs in health facilities in Lagos State. We further identified pertinent contextual factors that need to be addressed when developing ASPs in healthcare facilities in a resource-poor setting.
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Affiliation(s)
- Emelda E. Chukwu
- Antimicrobial Resistance Research group, Nigerian Institute of Medical Research, Yaba, Lagos State, Nigeria
| | - Dennis Abuh
- Antimicrobial Resistance Research group, Nigerian Institute of Medical Research, Yaba, Lagos State, Nigeria
| | - Ifeoma E. Idigbe
- Antimicrobial Resistance Research group, Nigerian Institute of Medical Research, Yaba, Lagos State, Nigeria
| | - Kazeem A. Osuolale
- Antimicrobial Resistance Research group, Nigerian Institute of Medical Research, Yaba, Lagos State, Nigeria
| | - Vivian Chuka-Ebene
- Antimicrobial Resistance Research group, Nigerian Institute of Medical Research, Yaba, Lagos State, Nigeria
- Pharmacy Department, Lagos University Teaching Hospital, Lagos, Lagos State, Nigeria
| | - Oluwatoyin Awoderu
- Antimicrobial Resistance Research group, Nigerian Institute of Medical Research, Yaba, Lagos State, Nigeria
| | - Rosemary A. Audu
- Antimicrobial Resistance Research group, Nigerian Institute of Medical Research, Yaba, Lagos State, Nigeria
| | - Folasade T. Ogunsola
- Antimicrobial Resistance Research group, Nigerian Institute of Medical Research, Yaba, Lagos State, Nigeria
- Department of Medical Microbiology and Parasitology, College of Medicine, University of Lagos, Lagos, Nigeria
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Tjilos M, Drainoni ML, Burrowes SAB, Butler JM, Damschroder LJ, Bidwell Goetz M, Madaras-Kelly K, Reardon CM, Samore MH, Shen J, Stenehjem EA, Zhang Y, Barlam TF. A qualitative evaluation of frontline clinician perspectives toward antibiotic stewardship programs. Infect Control Hosp Epidemiol 2023; 44:1995-2001. [PMID: 36987859 PMCID: PMC10755145 DOI: 10.1017/ice.2023.35] [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: 11/21/2022] [Revised: 02/02/2023] [Accepted: 02/04/2023] [Indexed: 03/30/2023]
Abstract
OBJECTIVE To examine the perspectives of caregivers that are not part of the antibiotic stewardship program (ASP) leadership team (eg, physicians, nurses, and clinical pharmacists), but who interact with ASPs in their role as frontline healthcare workers. DESIGN Qualitative semistructured interviews. SETTING The study was conducted in 2 large national healthcare systems including 7 hospitals in the Veterans' Health Administration and 4 hospitals in Intermountain Healthcare. PARTICIPANTS We interviewed 157 participants. The current analysis includes 123 nonsteward clinicians: 47 physicians, 26 pharmacists, 29 nurses, and 21 hospital leaders. METHODS Interviewers utilized a semistructured interview guide based on the Consolidated Framework for Implementation Research (CFIR), which was tailored to the participant's role in the hospital as it related to ASPs. Qualitative analysis was conducted using a codebook based on the CFIR. RESULTS We identified 4 primary perspectives regarding ASPs. (1) Non-ASP pharmacists considered antibiotic stewardship activities to be a high priority despite the added burden to work duties: (2) Nurses acknowledged limited understanding of ASP activities or involvement with these programs; (3) Physicians criticized ASPs for their restrictions on clinical autonomy and questioned the ability of antibiotic stewards to make recommendations without the full clinical picture; And (4) hospital leaders expressed support for ASPs and recognized the unique challenges faced by non-ASP clinical staff. CONCLUSION Further understanding these differing perspectives of ASP implementation will inform possible ways to improve ASP implementation across clinical roles.
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Affiliation(s)
- Maria Tjilos
- Department of Community Health Sciences, School of Public Health, Boston University, BostonMassachusetts
| | - Mari-Lynn Drainoni
- Section of Infectious Diseases, Department of Medicine, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
- Department of Health Law, Policy and Management, School of Public Health, Boston University, Boston, Massachusetts
- Evans Center for Implementation and Improvement Sciences, Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
| | - Shana A. B. Burrowes
- Section of Infectious Diseases, Department of Medicine, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
| | - Jorie M. Butler
- Division of Geriatrics, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
- Geriatric Education and Clinical Center and IDEAS Center of Innovation, Veterans’ Affairs (VA) Salt Lake City Health Care System, Salt Lake City, Utah
| | - Laura J. Damschroder
- VA Center for Clinical Management Research, Department of Veterans’ Affairs, Ann Arbor, Michigan
| | - Matthew Bidwell Goetz
- VA Greater Los Angeles Healthcare System, Los Angeles, California
- David Geffen School of Medicine, UCLA, Los Angeles, California
| | - Karl Madaras-Kelly
- Boise VA Medical Center, Boise, Idaho
- College of Pharmacy, Idaho State University, MeridianIdaho
| | - Caitlin M. Reardon
- VA Center for Clinical Management Research, Department of Veterans’ Affairs, Ann Arbor, Michigan
| | - Matthew H. Samore
- IDEAS Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, Utah
- Divison of Epidemiology, Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Jincheng Shen
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah
| | - Edward A. Stenehjem
- Division of Infectious Diseases and Epidemiology, Intermountain Healthcare, Salt Lake City, Utah
| | - Yue Zhang
- Divison of Epidemiology, Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Tamar F. Barlam
- Section of Infectious Diseases, Department of Medicine, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
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Nelson GE, Narayanan N, Onguti S, Stanley K, Newland JG, Doernberg SB. Principles and Practice of Antimicrobial Stewardship Program Resource Allocation. Infect Dis Clin North Am 2023; 37:683-714. [PMID: 37735012 DOI: 10.1016/j.idc.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/23/2023]
Abstract
Antimicrobial Stewardship Programs (ASP) improve individual patient outcomes and clinical care processes while reducing antimicrobial-associated adverse events, optimizing operational priorities, and providing institutional cost savings. ASP composition, resources required, and priority focuses are influenced by myriad factors. Despite robust evidence and broad national support, individual ASPs still face challenges in obtaining appropriate resources. Though understanding the current landscape of ASP resource allocation, factors influencing staffing needs, and strategies required to obtain desired resources is important, acceptance of recommended staffing levels and appropriate ASP resource allocation are much needed to facilitate ASP sustainability and growth across the complex and diverse health care continuum.
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Affiliation(s)
- George E Nelson
- Department of Medicine, Division of Infectious Diseases, Vanderbilt University Medical Center, 1161 21st Avenue South, A2200 MCN, Nashville, TN 37232-2582, USA.
| | - Navaneeth Narayanan
- Department of Pharmacy Practice and Administration, Rutgers University Ernest Mario School of Pharmacy, 160 Frelinghuysen Road, Piscataway, NJ 08854, USA
| | - Sharon Onguti
- Department of Medicine, Division of Infectious Diseases, Vanderbilt University Medical Center, 1161 21st Avenue South, A2200 MCN, Nashville, TN 37232-2582, USA
| | - Kim Stanley
- Department of Quality and Patient Safety, Division of Hospital Epidemiology and Infection Prevention, University of San Francisco, California, San Francisco, CA, USA
| | - Jason G Newland
- Department of Pediatrics, Division of Infectious Diseases, Washington University School of Medicine, 660 South Euclid Avenue, St Louis, MO 63110, USA
| | - Sarah B Doernberg
- Department of Medicine, Division of Infectious Diseases, University of San Francisco, California, 513 Parnassus Avenue, Box 0654, San Francisco, CA 94143, USA
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Facilitators and barriers to implementing antimicrobial stewardship programs in public South African hospitals. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e34. [PMID: 36865702 PMCID: PMC9972532 DOI: 10.1017/ash.2022.355] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 11/15/2022] [Accepted: 11/15/2022] [Indexed: 02/25/2023]
Abstract
Objective The South African National Department of Health released guidelines and recommendations for antimicrobial stewardship (AMS) programs to be established in public healthcare facilities. Their implementation remains challenged, especially in North West Province, where the public health system functions under severe strain. This research explored and interpreted the facilitators that strengthen and barriers that hinder the implementation of the national AMS program in public hospitals in North West Province. Design A qualitative design and interpretive descriptive approach enabled insight into the realities of AMS program implementation. Setting Public hospitals in North West Province, sampled through criterion sampling (n = 5). Participants Purposive criterion sampling of healthcare practitioners (n = 30) actively participating in AMS programs in the 5 sampled public hospitals. Method Qualitative, interpretive description with semi-structured individual interviews that were digitally recorded and transcribed. The ATLAS.ti version 8 software facilitated content analysis, followed by second-level analysis. Results In total, 4 themes, 13 categories, and 25 subcategories emerged. We detected dissonance between government AMS ideals and the realities of AMS program implementation in public hospitals. A multilevel AMS leadership and governance vacuum exists in a dysfunctional health ecosystem in which AMS must operate. Healthcare practitioners agreed on the importance of AMS despite different understandings of AMS and ineffective multidisciplinary teams. Discipline-specific education and training are essential for all AMS participants. Conclusions AMS is essential yet complex, and its contextualization and implementation are underestimated in public hospitals. Recommendations are focused on a supportive organizational culture, contextualized AMS program implementation plans, and changes in management.
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Kim CJ. Current Status of Antibiotic Stewardship and the Role of Biomarkers in Antibiotic Stewardship Programs. Infect Chemother 2022; 54:674-698. [PMID: 36596680 PMCID: PMC9840952 DOI: 10.3947/ic.2022.0172] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 12/19/2022] [Indexed: 12/27/2022] Open
Abstract
The importance of antibiotic stewardship is increasingly emphasized in accordance with the increasing incidences of multidrug-resistant organisms and accompanying increases in disease burden. This review describes the obstacles in operating an antibiotic stewardship program (ASP), and whether the use of biomarkers within currently available resources can help. Surveys conducted around the world have shown that major obstacles to ASPs are shortages of time and personnel, lack of appropriate compensation for ASP operation, and lack of guidelines or appropriate manuals. Sufficient investment, such as the provision of full-time equivalent ASP practitioners, and adoption of computerized clinical decision systems are useful measures to improve ASP within an institution. However, these methods are not easy in terms of both time commitments and cost. Some biomarkers, such as C-reactive protein, procalcitonin, and presepsin are promising tools in ASP due to their utility in diagnosis and forecasting the prognosis of sepsis. Recent studies have demonstrated the usefulness of algorithmic approaches based on procalcitonin level to determine the initiation or discontinuation of antibiotics, which would be helpful in decreasing antibiotics use, resulting in more appropriate antibiotics use.
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Affiliation(s)
- Chung-Jong Kim
- Department of Internal Medicine, College of Medicine, Ewha Womans University, Seoul, Korea
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Antibiotic stewardship implementation at hospitals without on-site infectious disease specialists: A qualitative study. Infect Control Hosp Epidemiol 2021; 43:576-581. [PMID: 33993897 PMCID: PMC9096709 DOI: 10.1017/ice.2021.203] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Hospitals are required to have antibiotic stewardship programs (ASPs), but there are few models for implementing ASPs without the support of an infectious disease (ID) specialist, defined as an ID physician and/or ID pharmacist. OBJECTIVE In this study, we sought to understand ASP implementation at hospitals that lack on-site ID support within the Veterans' Health Administration (VHA). METHODS Using a mandatory VHA survey, we identified acute-care hospitals that lacked an on-site ID specialist. We conducted semistructured interviews with personnel involved in ASP activities. SETTING The study was conducted across 7 VHA hospitals. PARTICIPANTS In total, 42 hospital personnel were enrolled in the study. RESULTS The primary responsibility for ASPs fell on the pharmacist champions, who were typically assigned multiple other non-ASP responsibilities. The pharmacist champions were more successful at gaining buy-in when they had established rapport with clinicians, but at some sites, the use of contract physicians and frequent staff turnover were potential barriers. Some sites felt that having access to an off-site ID specialist was important for overcoming institutional barriers and improving the acceptance of their stewardship recommendations. In general, stewardship champions struggled to mobilize institutional resources, which made it difficult to advance their programmatic goals. CONCLUSION In this study of 7 hospitals without on-site ID support, we found that ASPs are largely a pharmacy-driven process. Remote ID support, if available, was seen as helpful for implementing stewardship interventions. These findings may inform the future implementation of ASPs in settings lacking local ID expertise.
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Saleh D, Abu-Farha R, Mukattash TL, Barakat M, Alefishat E. Views of Community Pharmacists on Antimicrobial Resistance and Antimicrobial Stewardship in Jordan: A Qualitative Study. Antibiotics (Basel) 2021; 10:antibiotics10040384. [PMID: 33916855 PMCID: PMC8067308 DOI: 10.3390/antibiotics10040384] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 03/19/2021] [Accepted: 04/01/2021] [Indexed: 12/18/2022] Open
Abstract
The Center for Disease Control and Prevention and the World Health Organization issued a practical approach and Global Action Plan to control the threatening emerging antibacterial resistance. One of the main bases of this plan is the Antimicrobial Stewardship Program (ASPs). This study aimed to evaluate community pharmacists’ awareness and perception towards antimicrobial resistance and ASPs in Jordan. Thus, a qualitative study was conducted through in-depth interviews with twenty community pharmacists. Convenience sampling was used in the study. Qualitative analysis of the data yielded four themes and eleven sub-themes. All the respondents showed a good understanding of the causes of antimicrobial resistance. The most important cause reported by them was the non-restricted prescription of antimicrobials. Most of the pharmacists believed that they are competent to provide ASPs, however, they believed that there are several barriers against the implementation of ASPs in community pharmacies in Jordan. Barriers demonstrated by the pharmacists, included organizational obstacles, resources obstacles, and personal obstacles. In conclusion, this study revealed several barriers against the implementation of ASPs in community pharmacies in Jordan. Incorporating ASPs in the community pharmacy settings requires proper pharmacist training, several academic disciplines team efforts, and good pharmacy practice of antimicrobial guidelines.
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Affiliation(s)
- Doaa Saleh
- Department of Clinical Pharmacy and Therapeutics, Faculty of Pharmacy, Applied Science Private University, Amman 11937, Jordan; (D.S.); (R.A.-F.); (M.B.)
| | - Rana Abu-Farha
- Department of Clinical Pharmacy and Therapeutics, Faculty of Pharmacy, Applied Science Private University, Amman 11937, Jordan; (D.S.); (R.A.-F.); (M.B.)
| | - Tareq L. Mukattash
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid 22110, Jordan;
| | - Muna Barakat
- Department of Clinical Pharmacy and Therapeutics, Faculty of Pharmacy, Applied Science Private University, Amman 11937, Jordan; (D.S.); (R.A.-F.); (M.B.)
| | - Eman Alefishat
- Department Biopharmaceutics and Clinical Pharmacy, Faculty of Pharmacy, The University of Jordan, Amman 11937, Jordan
- Department of Pharmacology, College of Medicine and Health Science, Khalifa University of Science and Technology, Abu Dhabi 127788, United Arab Emirates
- Center for Biotechnology, Khalifa University of Science and Technology, Abu Dhabi 127788, United Arab Emirates
- Correspondence: ; Tel.: +971-5018466
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Mapping the Implementation of a Clinical Pharmacist-Driven Antimicrobial Stewardship Programme at a Tertiary Care Centre in South India. Antibiotics (Basel) 2021; 10:antibiotics10020220. [PMID: 33672095 PMCID: PMC7926893 DOI: 10.3390/antibiotics10020220] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 01/01/2021] [Accepted: 01/05/2021] [Indexed: 11/17/2022] Open
Abstract
In many parts of the world, including in India, pharmacist roles in antimicrobial stewardship (AMS) programmes remain unexplored. We describe the evolution and effect of the role of adding clinical pharmacists to a multidisciplinary AMS at a tertiary care teaching hospital in Kerala, India. Through effective leadership, multidisciplinary AMS (February 2016) and antitubercular therapy (ATT) stewardship programmes (June 2017) were established. Clinical pharmacists were introduced as core members of the programmes, responsible for the operational delivery of key stewardship interventions. Pharmacy-led audit and feedback monitored the appropriateness of antimicrobial prescriptions and compliance to AMS/ATT recommendations. Between February 2016 and January 2017, 56% (742/1326) of antimicrobial prescriptions were appropriate, and 54% (318/584) of recommendations showed compliance. By the third year of the AMS, appropriateness increased to 80% (1752/2190), and compliance to the AMS recommendations to 70% (227/325). The appropriateness of ATT prescriptions increased from a baseline of 61% (95/157) in the first year, to 72% (62/86, June 2018-February 2019). The compliance to ATT recommendations increased from 42% (25/60) to 58% (14/24). Such a model can be effective in implementing sustainable change in low- and middle-income countries (LMICs) such as India, where the shortage of infectious disease physicians is a major impediment to the implementation and sustainability of AMS programmes.
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Survey of physician and pharmacist steward perceptions of their antibiotic stewardship programs. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY 2021; 1:e48. [PMID: 36168491 PMCID: PMC9495632 DOI: 10.1017/ash.2021.219] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 08/27/2021] [Accepted: 09/27/2021] [Indexed: 11/17/2022]
Abstract
Objective: To examine how individual steward characteristics (eg, steward role, sex, and specialized training) are associated with their views of antimicrobial stewardship program (ASP) implementation at their institution. Design: Descriptive survey from a mixed-methods study. Setting: Two large national healthcare systems; the Veterans’ Health Administration (VA) (n = 134 hospitals) and Intermountain Healthcare (IHC; n = 20 hospitals). Participants: We sent the survey to 329 antibiotic stewards serving in 154 hospitals; 152 were physicians and 177 were pharmacists. In total, 118 pharmacists and 64 physicians from 126 hospitals responded. Methods: The survey was grounded in constructs of the Consolidated Framework for Implementation Research, and it assessed stewards’ views on the development and implementation of antibiotic stewardship programs (ASPs) at their institutions We then examined differences in stewards’ views by demographic factors. Results: Regardless of individual factors, stewards agreed that the ASP added value to their institution and was advantageous to patient care. Stewards also reported high levels of collegiality and self-efficacy. Stewards who had specialized training or those volunteered for the role were less likely to think that the ASP was implemented due to a mandate. Similarly volunteers and those with specialized training felt that they had authority in the antibiotic decisions made in their facility. Conclusions: Given the importance of ASPs, it may be beneficial for healthcare institutions to recruit and train individuals with a true interest in stewardship.
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The Case for Consultant Pharmacists as Key Players in Nursing Home Antibiotic Stewardship Programs. J Am Med Dir Assoc 2020; 22:6-8. [PMID: 33271122 DOI: 10.1016/j.jamda.2020.11.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 11/24/2020] [Indexed: 01/20/2023]
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Goebel MC, Trautner BW, Wang Y, Van JN, Dillon LM, Patel PK, Drekonja DM, Graber CJ, Shukla BS, Lichtenberger P, Helfrich CD, Sales A, Grigoryan L. Organizational readiness assessment in acute and long-term care has important implications for antibiotic stewardship for asymptomatic bacteriuria. Am J Infect Control 2020; 48:1322-1328. [PMID: 32437753 DOI: 10.1016/j.ajic.2020.04.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 04/29/2020] [Accepted: 04/30/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Prior to implementing an antibiotic stewardship intervention for asymptomatic bacteriuria (ASB), we assessed institutional barriers to change using the Organizational Readiness to Change Assessment. METHODS Surveys were self-administered on paper in inpatient medicine and long-term care units at 4 Veterans Affairs facilities. Participants included providers, nurses, and pharmacists. The survey included 7 subscales: evidence (perceived strength of evidence) and six context subscales (favorability of organizational context). Responses were scored on a 5-point Likert-type scale. RESULTS One hundred four surveys were completed (response rate = 69.3%). Overall, the evidence subscale had the highest score; the resources subscale (mean 2.8) was significantly lower than other subscales (P < .001). Scores for budget and staffing resources were lower than scores for training and facility resources (P < .001 for both). Pharmacists had lower scores than providers for the staff culture subscale (P = .04). The site with the lowest scores for resources (mean 2.4) also had lower scores for leadership and lower pharmacist effort devoted to stewardship. CONCLUSIONS Although healthcare professionals endorsed the evidence about nontreatment of ASB, perceived barriers to antibiotic stewardship included inadequate resources and leadership support. These findings provide targets for tailoring the stewardship intervention to maximize success.
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Tischendorf J, Brunner M, Knobloch MJ, Schulz L, Barker A, Wright MO, Lepak A, Safdar N. Evaluation of a successful fluoroquinolone restriction intervention among high-risk patients: A mixed-methods study. PLoS One 2020; 15:e0237987. [PMID: 32841259 PMCID: PMC7446965 DOI: 10.1371/journal.pone.0237987] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 08/06/2020] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE We conducted a quality improvement initiative to restrict fluoroquinolone prescribing on two inpatient units housing high-risk patients and applied a human factors approach to understanding the barriers and facilitators to success of this intervention by front-line providers. METHODS This was a mixed-methods, quasi-experimental study. This study was conducted on two inpatient units at a tertiary care academic medical center: the medical-surgical intensive care and abdominal solid organ transplant units. Unit-level data were collected retrospectively for 24 months pre- and post- fluoroquinolone restriction intervention, implemented in July 2016, for all admissions to the study units. Our restriction intervention required antimicrobial stewardship pre-approval for fluoroquinolone prescribing. We explored barriers and facilitators to optimal fluoroquinolone prescribing using semi-structured interviews attending, fellow and resident physicians, advanced practice providers and pharmacists on these units. RESULTS Hospital-onset C. difficile infection did not decrease significantly, but fluoroquinolone use declined significantly from 111.6 to 19.8 days of therapy per 1000 patient-days without negatively impacting length of stay, readmissions or mortality. Third generation cephalosporin and aminoglycoside use increased post-restriction. Providers identified our institution's strong antimicrobial stewardship program and pharmacy involvement in antimicrobial decision making as key facilitators of fluoroquinolone optimization and patient complexity, lack of provider education and organizational culture as barriers to optimal prescribing. CONCLUSIONS Fluoroquinolones can be safely restricted even among high-risk patients without negatively impacting length of stay, readmissions or mortality. Our study provides a framework for successful antimicrobial stewardship interventions informed by perceptions of front line providers.
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Affiliation(s)
- Jessica Tischendorf
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States of America
| | - Matthew Brunner
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States of America
| | - Mary Jo Knobloch
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States of America
- William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin, United States of America
| | - Lucas Schulz
- Department of Pharmacy, University of Wisconsin Hospital and Clinics, Madison, Wisconsin, United States of America
| | - Anna Barker
- Department of Population Health Sciences, University of Wisconsin Madison, Madison, Wisconsin, United States of America
- Department of Internal Medicine, University of Michigan Ann Arbor, Ann Arbor, Michigan, United States of America
| | - Marc-Oliver Wright
- Infection Prevention Program, University of Wisconsin Hospital and Clinics, Madison, Wisconsin, United States of America
| | - Alexander Lepak
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States of America
| | - Nasia Safdar
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States of America
- William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin, United States of America
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14
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Keizer J, Beerlage-De Jong N, Al Naiemi N, van Gemert-Pijnen JEWC. Finding the match between healthcare worker and expert for optimal audit and feedback on antimicrobial resistance prevention measures. Antimicrob Resist Infect Control 2020; 9:125. [PMID: 32758300 PMCID: PMC7405438 DOI: 10.1186/s13756-020-00794-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 07/29/2020] [Indexed: 11/26/2022] Open
Abstract
Background The potentials of audit and feedback (AF) to improve healthcare are currently not exploited. To unlock the potentials of AF, this study focused on the process of making sense of audit data and translating data into actionable feedback by studying a specific AF-case: limiting antimicrobial resistance (AMR). This was done via audit and feedback of AMR prevention measures (APM) that are executed by healthcare workers (HCW) in their day-to-day contact with patients. This study’s aim was to counterbalance the current predominantly top-down, expert-driven audit and feedback approach for APM, with needs and expectations of HCW. Methods Qualitative semi-structured interviews were held with sixteen HCW (i.e. physicians, residents and nurses) from high-risk AMR departments at a regional hospital in The Netherlands. Deductive coding was succeeded by open and axial coding to establish main codes, subcodes and variations within codes. Results HCW demand insights from audits into all facets of APM in their working routines (i.e. diagnostics, treatment and infection control), preferably in the form of simple and actionable feedback that invites interdisciplinary discussions, so that substantiated actions for improvement can be implemented. AF should not be seen as an isolated ad-hoc intervention, but as a recurrent, long-term, and organic improvement strategy that balances the primary aims of HCW (i.e. improving quality and safety of care for individual patients and HCW) and AMR-experts (i.e. reducing the burden of AMR). Conclusions To unlock the learning and improvement potentials of audit and feedback, HCW’ and AMR-experts’ perspectives should be balanced throughout the whole AF-loop (incl. data collection, analysis, visualization, feedback and planning, implementing and monitoring actions). APM-AF should be flexible, so that both audit (incl. collecting and combining the right data in an efficient and transparent manner) and feedback (incl. persuasive and actionable feedback) can be tailored to the needs of various target groups. To balance HCW’ and AMR-experts’ perspectives a participatory holistic AF development approach is advocated.
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Affiliation(s)
- J Keizer
- Centre for eHealth and Wellbeing Research, Department of Psychology, Health and Technology, University of Twente, P.O. Box 217, Enschede, 7500AE, The Netherlands.
| | - N Beerlage-De Jong
- Centre for eHealth and Wellbeing Research, Department of Psychology, Health and Technology, University of Twente, P.O. Box 217, Enschede, 7500AE, The Netherlands
| | - N Al Naiemi
- Department of Infection Prevention, Hospital Group Twente, Almelo/Hengelo, The Netherlands.,LabMicTA, Hengelo, The Netherlands
| | - J E W C van Gemert-Pijnen
- Centre for eHealth and Wellbeing Research, Department of Psychology, Health and Technology, University of Twente, P.O. Box 217, Enschede, 7500AE, The Netherlands
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15
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Currie K, Laidlaw R, Ness V, Gozdzielewska L, Malcom W, Sneddon J, Seaton RA, Flowers P. Mechanisms affecting the implementation of a national antimicrobial stewardship programme; multi-professional perspectives explained using normalisation process theory. Antimicrob Resist Infect Control 2020; 9:99. [PMID: 32616015 PMCID: PMC7330968 DOI: 10.1186/s13756-020-00767-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 06/23/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Antimicrobial stewardship (AMS) describes activities concerned with safe-guarding antibiotics for the future, reducing drivers for the major global public health threat of antimicrobial resistance (AMR), whereby antibiotics are less effective in preventing and treating infections. Appropriate antibiotic prescribing is central to AMS. Whilst previous studies have explored the effectiveness of specific AMS interventions, largely from uni-professional perspectives, our literature search could not find any existing evidence evaluating the processes of implementing an integrated national AMS programme from multi-professional perspectives. METHODS This study sought to explain mechanisms affecting the implementation of a national antimicrobial stewardship programme, from multi-professional perspectives. Data collection involved in-depth qualitative telephone interviews with 27 implementation lead clinicians from 14/15 Scottish Health Boards and 15 focus groups with doctors, nurses and clinical pharmacists (n = 72) from five Health Boards, purposively selected for reported prescribing variation. Data was first thematically analysed, barriers and enablers were then categorised, and Normalisation Process Theory (NPT) was used as an interpretive lens to explain mechanisms affecting the implementation process. Analysis addressed the NPT questions 'which group of actors have which problems, in which domains, and what sort of problems impact on the normalisation of AMS into everyday hospital practice'. RESULTS Results indicated that major barriers relate to organisational context and resource availability. AMS had coherence for implementation leads and prescribing doctors; less so for consultants and nurses who may not access training. Conflicting priorities made obtaining buy-in from some consultants difficult; limited role perceptions meant few nurses or clinical pharmacists engaged with AMS. Collective individual and team action to implement AMS could be constrained by lack of medical continuity and hierarchical relationships. Reflexive monitoring based on audit results was limited by the capacity of AMS Leads to provide direct feedback to practitioners. CONCLUSIONS This study provides original evidence of barriers and enablers to the implementation of a national AMS programme, from multi-professional, multi-organisational perspectives. The use of a robust theoretical framework (NPT) added methodological rigour to the findings. Our results are of international significance to healthcare policy makers and practitioners seeking to strengthen the sustainable implementation of hospital AMS programmes in comparable contexts.
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Affiliation(s)
- Kay Currie
- Glasgow Caledonian University, Glasgow, UK.
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16
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Barlam TF, Childs E, Zieminski SA, Meshesha TM, Jones KE, Butler JM, Damschroder LJ, Goetz MB, Madaras-Kelly K, Reardon CM, Samore MH, Shen J, Stenehjem E, Zhang Y, Drainoni ML. Perspectives of Physician and Pharmacist Stewards on Successful Antibiotic Stewardship Program Implementation: A Qualitative Study. Open Forum Infect Dis 2020; 7:ofaa229. [PMID: 32704510 PMCID: PMC7367692 DOI: 10.1093/ofid/ofaa229] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 06/08/2020] [Indexed: 11/14/2022] Open
Abstract
Background Antibiotic stewardship programs (ASPs) are required at every hospital regardless of size. We conducted a qualitative study across different hospital settings to examine perspectives of physician and pharmacist stewards about the dynamics within their team and contextual factors that facilitate the success of their programs. Methods Semistructured interviews were conducted in March-November 2018 with 46 ASP stewards, 30 pharmacists, and 16 physicians, from 39 hospitals within 2 large hospital systems. Results We identified 5 major themes: antibiotic stewards were enthusiastic about their role, committed to the goals of stewardship for their patients and as a public-health imperative, and energized by successful interventions; responsibilities of pharmacist and physician stewards are markedly different, and pharmacy stewards performed the majority of the day-to-day stewardship work; collaborative teamwork is important to improving care, the pharmacists and physicians supported each other, and pharmacists believed that having a strong physician leader was essential; provider engagement strategies are a critical component of stewardship, and recommendations must be communicated in a collegial manner that did not judge the provider competence, preferably through face-to-face interactions; and hospital leadership support for ASP goals and for protected time for ASP activities is critical for success. Conclusions The physician-pharmacist team is essential for ASPs; most have pharmacists leading and performing day-to-day activities with physician support. Collaborative, persuasive approaches for ASP interventions were the norm. Stewards were careful not to criticize or judge inappropriate antibiotic prescribing. Further research should examine whether this persuasive approach undercuts provider appreciation of stewardship as a public health mandate.
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Affiliation(s)
- Tamar F Barlam
- Section of Infectious Diseases, Department of Medicine, School of Medicine, Boston University, Boston, Massachusetts, USA
| | - Ellen Childs
- Department of Health Law, Policy and Management, School of Public Health, Boston University, Boston, Massachusetts, USA
| | - Sarah A Zieminski
- Section of Infectious Diseases, Department of Medicine, School of Medicine, Boston University, Boston, Massachusetts, USA
| | - Tsega M Meshesha
- Department of Health Law, Policy and Management, School of Public Health, Boston University, Boston, Massachusetts, USA
| | - Kathryn E Jones
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
| | - Jorie M Butler
- Department of Internal Medicine, Division of Geriatrics, University of Utah; Geriatric Education and Clinical Center and IDEAS Center of Innovation, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah, USA
| | - Laura J Damschroder
- VA Center for Clinical Management Research, Department of Veterans Affairs, Ann Arbor, Michigan, USA
| | - Matthew Bidwell Goetz
- Veterans Affairs Greater Los Angeles Healthcare System; David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | - Karl Madaras-Kelly
- Boise Veterans Affairs Medical Center; College of Pharmacy, Idaho State University, Meridian, Idaho, USA
| | - Caitlin M Reardon
- VA Center for Clinical Management Research, Department of Veterans Affairs, Ann Arbor, Michigan, USA
| | - Matthew H Samore
- IDEAS Center of Innovation, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah, USA.,Division of Epidemiology, Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Jincheng Shen
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah, USA
| | - Edward Stenehjem
- Office of Patient Experience, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Yue Zhang
- Division of Epidemiology, Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Mari-Lynn Drainoni
- Section of Infectious Diseases, Department of Medicine, School of Medicine, Boston University, Boston, Massachusetts, USA.,Department of Health Law, Policy and Management, School of Public Health, Boston University, Boston, Massachusetts, USA.,Evans Center for Implementation and Improvement Sciences, Department of Medicine, School of Medicine, Boston University, Boston, Massachusetts, USA.,Center for Healthcare Organization and Implementation Research, ENRM VA Hospital, Boston, Massachusetts, USA
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