Covering more Territory to Fight Resistance: Considering Nurses' Role in Antimicrobial Stewardship

Knowledge, Attitudes, and Practices toward Antimicrobial Resistance among Young Italian Nurses and Students: A Multicenter, Cross-Sectional Study

Background: Nurses play a pivotal role in combating antimicrobial resistance (AMR). However, the success of local and national AMR containment efforts hinges on the knowledge, attitude, and practice (KAP) of nursing staff and undergraduate students. Objectives: This study aims to explore the determinants of nurses' KAP regarding AMR, offering insights to control the emergence and spread of drug-resistant pathogens. Methods: This cross-sectional, multicenter survey involving Italian nurses, nursing students, and healthcare professionals was conducted administering an anonymous online questionnaire focusing on AMR. The median score of 12 was taken as the cutoff for "good KAP." The association between study variables and good KAP was assessed using chi-square or t-tests, followed by multivariable logistic regression analysis for statistically significant (p < 0.05) variables. Findings: Among 848 participants, 61.9% (n = 525) were students, and 39.6% (n = 336) scored as having "low KAP." High KAP was associated with being female and studying AMR independently. Conversely, living in southern Italy and receiving AMR training from pharmaceutical companies were associated with low KAP. Conclusions: Among Italian nurses, AMR awareness relies on those who have studied AMR as self-taught and is affected by gender and region. Italian universities lack in lectures on AMR management, and much needs to be done to improve awareness of antimicrobial stewardship among nonmedical health workers.

Clostridioides difficile infection: history, epidemiology, risk factors, prevention, clinical manifestations, treatment, and future options

SUMMARYClostridioides difficile infection (CDI) is one of the major issues in nosocomial infections. This bacterium is constantly evolving and poses complex challenges for clinicians, often encountered in real-life scenarios. In the face of CDI, we are increasingly equipped with new therapeutic strategies, such as monoclonal antibodies and live biotherapeutic products, which need to be thoroughly understood to fully harness their benefits. Moreover, interesting options are currently under study for the future, including bacteriophages, vaccines, and antibiotic inhibitors. Surveillance and prevention strategies continue to play a pivotal role in limiting the spread of the infection. In this review, we aim to provide the reader with a comprehensive overview of epidemiological aspects, predisposing factors, clinical manifestations, diagnostic tools, and current and future prophylactic and therapeutic options for C. difficile infection.

A hidden gem in multidisciplinary antimicrobial stewardship: a systematic review on bedside nurses' activities in daily practice regarding antibiotic use

Background

Antimicrobial stewardship (AMS), the set of actions to ensure antibiotics are used appropriately, is increasingly targeted at all those involved in the antimicrobial pathway, including nurses. Several healthcare organizations have issued position statements on how bedside nurses can be involved in AMS. However, it remains unclear how nurses, in reality, contribute to appropriate antibiotic use.

Objectives

To systematically search the literature to describe the activities bedside nurses perform regarding antibiotic use in daily clinical practice, in relation to the activities proposed by the aforementioned position statements.

Methods

We searched MEDLINE, Embase, CINAHL and grey literature until March 2021. Studies were included if they described activities regarding antibiotic use performed by bedside nurses. Methodological rigour was assessed by applying the Mixed Method Appraisal Tool.

Results

A total of 118 studies were included. The majority of the proposed nurses' activities were found in daily practice, categorized into assessment of clinical status, collection of specimens, management of antimicrobial medication, prompting review and educating patient and relatives. Nurses may take the lead in these clinical processes and are communicators in all aspects of the antimicrobial pathway. Patient advocacy appears to be a strong driver of bedside nurses' activities.

Conclusions

Nurses' activities are already integrated in the day-to-day nursing practice and are grounded in the essence of nursing, being a patient advocate and showing nursing leadership in safeguarding the antimicrobial treatment process. An essential element of the nursing role is communication with other stakeholders in the patient-centred antimicrobial pathway. Educating, engaging and empowering nurses in this already integrated role, could lead to a solid, impactful nursing contribution to AMS.

Bedside nurses' antimicrobial stewardship practice scope and competencies in acute hospital settings: A scoping review

AIM

To identify and map bedside nurses' practice scope and competencies regarding antimicrobial stewardship in acute hospital settings, and develop a competency framework for them.

BACKGROUND

Antimicrobial stewardship requires multidisciplinary engagement including nursing. However, bedside nurses' antimicrobial stewardship practice scope and competencies in acute hospital settings remain unclear.

DESIGN

Scoping review.

METHODS

Using a five-stage framework proposed by Arksey and O'Malley and following the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews guidelines.

RESULTS

A total of 1422 records were retrieved, and 41 studies were included. In addition to the six practices recommended, this review summarized bedside nurses' contributions to five additional fields as well. Correspondingly, the competencies required by bedside nurses were summarized into eight domains: specialized knowledge, safety medication administration, leadership, education, diagnostic stewardship, infection prevention and control, professional development and professional quality.

CONCLUSION

Nurses' practice scope overlaps greatly with routine nursing practice in antimicrobial stewardship, confirming the evidence that nurses are ideal partners in antimicrobial stewardship. This review developed a competency framework at both basic and advanced levels. Among them, professional knowledge is the foundation, while professional quality motivates nurses to participate. In addition to competency assessment, it can also be used for training and human resource deployment based on seniority or professional level. This could bridge the knowledge gap and improve the engagement of nurses in heavy workload situations.

RELEVANCE TO CLINICAL PRACTICE

This practice scope will provide opportunities for nurses to engage in antimicrobial stewardship. Moreover, nursing competencies identified in this field could facilitate the development of competency-based education interventions, talent assessments, training and recruitment programs.

DATA RESOURCES

PubMed, EMBASE, Web of Science, CINHAL, PsycINFO, Cochrane Library, ProQuest and Scopus were searched from inception to November 2022, with an updated search in March 2023.

IMPACT

This scoping review provides evidence for best nursing practice scope and competency in antimicrobial stewardship in hospitals. However, it is also in line with the commitment of all nurses in the global community to combat antimicrobial resistance, which has become a global threat. An antimicrobial stewardship competency framework for bedside nurses was developed at both the basic and advanced levels. It would facilitate talent assessment, training, recruitment and human resource management by guiding the development of competency-based education interventions.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution.

A National Survey of Neonatal Nurses' Knowledge, Beliefs, and Practices of Antibiotic Stewardship

BACKGROUND

In the neonatal intensive care unit, implementation of antibiotic stewardship programs has been challenging, especially for staff nurses.

PURPOSE

To identify neonatal nurses' knowledge and attitudes toward antibiotic stewardship programs in neonatal intensive care units.

METHODS

This was a descriptive survey study to assess knowledge, attitudes, and beliefs of neonatal nurses related to antibiotic stewardship. The survey consisted of 23 questions, 6 of which were open-ended. The questions evaluated perceptions of general understanding of antibiotic stewardship, administration of antibiotics, information and perspective about antibiotic use, antibiotic resistance, and availability and usage of resources and education related to antibiotics. The survey was posted online for about 3 months on the Web site of a professional organization of neonatal nurses.

RESULTS

Of the 78 neonatal nurses who responded to the survey, 39% were very familiar with the term antibiotic stewardship . The majority of participants did not question the treating provider about the choice, route, or dose of antibiotics. The majority also agreed that more education is needed to achieve the goal of incorporating principles of antibiotic stewardship more fully into practice in the neonatal intensive care unit.

IMPLICATIONS FOR PRACTICE

Results suggest that although most nurses are familiar with the term antibiotic stewardship , they would like to have more education on the appropriate use of antibiotics.

IMPLICATIONS FOR RESEARCH

Further studies are needed to identify nurse involvement in applying the principles of antibiotic stewardship programs while working with the vulnerable population of preterm infants.

Antibiotic Stewardship Attitudes and Beliefs Among Frontline Staff Nurses: Impact of Virtual Education

Background: Nurses are vital healthcare team members and are often underutilised in antimicrobial stewardship (AS) activities. Several nursing responsibilities, such as taking allergy history and obtaining cultures, already overlap with AS activities. Nurses can play a crucial role in promoting AS in resource-limited settings. This study was conducted to assess frontline staff nurses’ baseline attitudes and beliefs towards AS, and see if a virtual education campaign consisting of newsletters and tip sheets would affect those attitudes and beliefs. Methods: An online survey (pre-survey) was conducted of all in-patient nurses employed in the authors’ hospital on their attitudes and beliefs regarding AS. The survey consisted of 24 questions divided into three domains: demographic and practice information, nursing roles, and beliefs and attitudes towards AS programmes (ASP). After obtaining the results of the pre-survey, the authors started distributing monthly newsletters on various AS topics via email and posting them on a resource page. Topics included how to obtain an accurate allergy history, how to use microbiology results to help guide decisions, and stop therapy in cases of colonisation. The authors also distributed the same survey as a follow-up 6-month survey (post-survey) in March 2021 to gauge the impact of their virtual education efforts. Results: In total, 109 nurses working in the adult in-patient setting of the authors’ institution completed the pre-survey in September 2020, and 64 nurses completed the post-survey in March 2021. Overall, most nurses had a positive attitude towards AS tasks, and over 90% of those who responded in the pre-survey and post-survey agreed with the statement that nurses are antibiotic stewards, thought it was important or very important to obtain appropriate cultures, and understood the relationship between Clostridioides difficile and antibiotics. Most pre-survey respondents listed knowledge gaps in microbiology (47 out of 64 [86%]) and antibiotics (53 out of 64 [84%]) as well as scope of practice concerns (48 out of 64 [75%]) as barriers to nurse participation. The virtual education helped raise the familiarity with the ASP and more nurses in the post-survey said they were familiar with the stewardship programme compared with the pre-survey (48.4% versus 23.2%; p=0.001). Conclusions: This study showed that most nurses consider themselves antibiotic stewards and want to participate in AS activities; however, barriers to nursing involvement, such as lack of knowledge, scope of practice concerns, and time constraints, persist. Virtual education may be an option to increase nursing awareness and participation on ASPs in resource-limited settings.

Dismantling antibiotic infrastructures in residential aged care: The invisible work of antimicrobial stewardship (AMS)

Recent social science scholarship has sought to understand the visible and invisible impacts of how antibiotics are entrenched as infrastructures and put to work as a proxy for higher levels of care (clinical or otherwise) within modern healthcare. Using a qualitative research design, in this paper our aim is to draw attention to less visible aspects of antimicrobial stewardship (AMS) in residential aged care and their implications for nurse-led optimization of antibiotic use in these settings. By developing an account of the perceptions, experiences and practices of staff regarding the 'on the ground' work associated with implementing and upholding AMS objectives our study extends research on attempts to dismantle antibiotic infrastructures in Australian residential aged care facilities (RACF). Drawing on a review of relevant policies, empirical data is presented from fifty-six in-depth interviews conducted in 2021 with staff at 8 different RACFs. Interview participants included managers, nurses, and senior and junior personal care assistants. Our results suggest that registered nurses in residential aged care have been tasked with promoting antibiotic optimization and assigned with AMS responsibilities without sufficient authority and resourcing. A host of hidden care work associated with AMS strategies was evident, reinforcing some staff support for empirical antibiotic prescribing as a 'safety net' in uncertain clinical cases. We argue that this hidden work occurs where AMS strategies displace the infrastructural role previously performed by antibiotics, exposing structural gaps and pressures. The inability of organisational accounting systems and the broader AMS policy agenda to capture hidden AMS workflows in RACFs has consequences for future resourcing and organisational learning in ways that mean AMS gaps may remain unaddressed. These results support findings that AMS interventions might not be easily accepted by aged care staff in view of associated burdens which are under recognised and under supported in this domain.

Knowledge, Attitude and Beliefs of Nurses Regarding Antibiotic use and Prevention of Antibiotic Resistance

Introduction

Resistance to antibiotics is a threat confronting health care system worldwide. Nurses play a significant role in combating this threat.

Objectives

The present study examined the knowledge and attitude of nurses towards antibiotic use and prevention of antibiotic resistance.

Methods

The research involved a cross-sectional study conducted in a multi-cultural tertiary healthcare setting. The participants were 341 nurses. A structured self-administered questionnaire with a good validity and reliability (α = 0.7) was used.

Results

The nurses surveyed showed moderate awareness of antibiotic resistance and a fair attitude towards its prevention. There was no significant correlation of demographic features with their overall knowledge and attitude ( p > 0.05).

Conclusions

Nurses perform a crucial part in infection control, but often lack knowledge of methods to prevent antibiotic resistance. This paucity highlights the importance of tailored interventions to help nurses improve their awareness of antibiotic resistance and create a favorable attitude towards its prevention.

Antibiotic prescribing knowledge: A brief survey of providers and staff at an ambulatory cancer center during Antibiotic Awareness Week 2019

We surveyed healthcare professionals at a cancer center regarding their knowledge and perceptions of antibiotic use. Most knew the term “antimicrobial stewardship.” Nurses and other staff were less likely than pharmacists or providers to answer knowledge-based questions correctly. Opportunities exist to improve antibiotic knowledge among cancer center staff.

Guideline recommendations for antimicrobial stewardship education for clinical nursing practice in hospitals: A scoping review

Background

Antimicrobial stewardship (AMS) is a proactive healthcare intervention to improve patient outcomes by optimising antimicrobial use. Although nursing involvement is a recognised necessity, bedside nurses may not yet possess competencies to fulfil this role.

Objectives

To identify recommendations for AMS education for the bedside nurse in key global AMS guidelines.

Methods

Scoping review methodology was used to systematically search published and 'grey' literature in PubMed, EBSCOhost, Google Scholar, government websites and websites of professional societies and organisations. Search dates were from 1990 to 2020. Inclusion criteria were English language AMS guidelines for hospitals.

Results

Literature searches retrieved 1 824 articles, with 43 meeting the review inclusion criteria. Reference was made to AMS nursing education in 23 (53.4%) of the articles. Educational opportunities for nurses were recommended: inclusion of AMS concepts/content into undergraduate and postgraduate nursing curricula (n=12; 27.9%), in-hospital training (n=14; 32.5%) and continuing professional development (n=6; 13.9%). Recommendations for nursing education were as follows: role of AMS in preventing antimicrobial resistance (n=7; 16.2%), infection prevention and control (n=3; 6.9%), diagnostics in AMS (n=5; 11.6%), pharmacology (n=11; 25.5%) and collaboration (n=2; 4.6%). Identified nursing educational gaps were: nurses not recognising their role within AMS (n=5; 11.6%), inadequate nursing resources and expertise for dosing, pharmacokinetic/pharmacodynamic strategies and managing possible drug incompatibilities with extended/prolonged infusions (n=3; 6.9%), and inappropriate nurse disposal of antibiotic waste (n=1; 2.3%).

Conclusion

Although recommendations for nursing education were found in many key AMS guidelines, few guidelines provided detailed descriptions of the nursing competencies that were required for this role.

Contributions of the study

This study serves to compile and highlight previously little-known recommendations within key international antimicrobial stewardship (AMS) guidelines for the education of clinical nurses in their AMS role. It provides a summary of expected clinical nurse competencies. It adds to current discussion within the literature on how to improve and support this critical nursing role.

Implementing an Antimicrobial Stewardship Program in the Intensive Care Unit by Engaging Critical Care Nurses

The continuing rise in the incidence of multidrug-resistant organism infections has made combating this grave threat a national imperative. One of the most potent weapons in our arsenal against such organisms is the prudent use of antibiotics. Antimicrobial stewardship (AMS) programs aim to slow the development of antimicrobial resistance through judicious, monitored use of antibiotics. Traditionally, AMS programs have included pharmacists and physicians with training in AWS, infectious disease physicians, hospital leadership, microbiologists, and infection prevention professionals. Nurses are missing from AMS programs, especially intensive care nurses. Critical care nurses provide the majority of patient care to ICU patients and monitor the progress of the patient's condition. The ICU nurse is an obvious asset to the AMS programs. ICU nurses are well-educated autonomous professionals with a unique role in coordinating with the critical care team. Critical care nurses already perform numerous nursing tasks with AWS functions. This, together with their unique perspective makes them a valuable asset that has often been overlooked. Traditionally, perceived barriers have kept ICU nurses from joining AMS teams. By removing these barriers and engaging critical care nurses in the important work of AWS, we can strengthen our AMS team and achieve optimal outcomes for our patients.

Quality Improvement Interventions and Implementation Strategies for Urine Culture Stewardship in the Acute Care Setting: Advances and Challenges

PURPOSE OF REVIEW

The goal of this article is to highlight how and why urinalyses and urine cultures are misused, review quality improvement interventions to optimize urine culture utilization, and highlight how to implement successful, sustainable interventions to improve urine culture practices in the acute care setting.

RECENT FINDINGS

Quality improvement initiatives aimed at reducing inappropriate treatment of asymptomatic bacteriuria often focus on optimizing urine test utilization (i.e., urine culture stewardship). Urine culture stewardship interventions in acute care hospitals span the spectrum of quality improvement initiatives, ranging from strong systems-based interventions like suppression of urine culture results to weaker interventions that focus on clinician education alone. While most urine culture stewardship interventions have met with some success, overall results are mixed, and implementation strategies to improve sustainability are not well understood.

SUMMARY

Successful diagnostic stewardship interventions are based on an assessment of underlying key drivers and focus on multifaceted and complementary approaches. Individual intervention components have varying impacts on effectiveness, provider autonomy, and sustainability. The best urine culture stewardship strategies ultimately include both technical and socio-adaptive components with long-term, iterative feedback required for sustainability.

Guidelines for the hospital role of the clinical nurse in antimicrobial stewardship: A scoping review

Background

Antimicrobial stewardship aims to optimise the use of antimicrobial medicines to preserve the efficacy of these medicines and to contain antimicrobial resistance where possible. Nurses constitute the largest group of healthcare workers; however, the role played by nurses within current antimicrobial stewardship strategies is largely unacknowledged despite nurses being at point-of-care at the hospital bedside.

Objectives

To identify recommendations for the antimicrobial stewardship role of the bedside nurse in key global antimicrobial stewardship guidelines.

Methods

Scoping review methodology was used to systematically search published and 'grey' literature in PubMed, EBSCOhost, Google Scholar, government websites, and websites of professional societies and organisations. Search dates were 1990 to 2020. Inclusion criteria were English language antimicrobial stewardship guidelines for hospitals. Screening was conducted in two stages for title and abstract and then full text relevancy and documented according to the PRISMA Extension for Scoping Reviews.

Results

Of the 1 824 articles that were retrieved, only 43 met the inclusion criteria. Inclusion of the bedside nurse on the antimicrobial stewardship team occurred in 13.9% (n=6) of the papers. A role for the bedside nurse was recommended in antibiotic stewardship (32.5%; n=14), infection prevention and control (23.2%; n=10), and administration of antimicrobial medicines (20.9%; n=9) of reviewed documents. Other recommendations included the use of evidence-based antimicrobial stewardship (20.9%; n=9), collaboration with other healthcare staff (11.6%; n=5), facilitation of transition of care (18.6%; n=8), and nurse prescription of antibiotics (4.6%; n=2).

Conclusion

This scoping review highlights a slow but incremental increase in recognition of the role of the bedside nurse within the operational hub of antimicrobial stewardship strategies.

Contributions of the study

The present study was undertaken to fill the gap in the literature on clinical nurses' contribution in antimicrobial stewardship. The findings of the review largely demonstrate that multidisciplinary antimicrobial stewardship guidelines fail to view the bedside nurse as a contributor within antimicrobial stewardship strategies.

Nurse practitioners as antibiotic stewards: Examining prescribing patterns and perceptions

BACKGROUND

Advanced practice providers in the outpatient setting play a key role in antibiotic stewardship, yet little is known about how to engage these providers in stewardship activities and what factors influence their antibiotic prescribing practices.

METHODS

We used mixed methods to obtain data on practices and perceptions related to antibiotic prescribing by nurse practitioners (NP) and Veteran patients. We interviewed NPs working in the outpatient setting at one Veterans Affairs facility and conducted focus groups with Veterans. Emerging themes were mapped to the Systems Engineering Initiative for Patient Safety framework. We examined NP antibiotic prescribing data from 2017 to 2019.

RESULTS

We interviewed NPs and conducted Veteran focus groups. Nurse practitioners reported satisfaction with resources, including ready access to pharmacists and infectious disease specialists. Building patient trust was reported as essential to prescribing confidence level. Veterans indicated the need to better understand differences between viral and bacterial infections. NP prescribing patterns revealed a decline in antibiotics prescribed for upper respiratory illnesses over a 3-year period.

CONCLUSION

Outpatient NPs focus on educating the patient while balancing organizational access challenges. Further research is needed to determine how to include both NPs and patients when implementing outpatient antibiotic stewardship strategies. Further research is also needed to understand factors associated with the decline in nurse practitioner antibiotic prescribing observed in this study.

Understanding the complexities of antibiotic prescribing behaviour in acute hospitals: a systematic review and meta-ethnography

BACKGROUND

Antimicrobial resistance poses a serious global public health threat. Hospital misuse of antibiotics has contributed to this problem and evidence-based interventions are urgently needed to change inappropriate prescribing practices. This paper reports the first theoretical stage of a longer-term project to improve antibiotic prescribing in hospitals through design of an effective behaviour-change intervention.

METHODS

Qualitative synthesis using meta-ethnography of primary studies reporting doctors' views and experiences of antibiotic prescribing in hospitals for example, their barriers to appropriate prescribing. Twenty electronic databases were systematically searched over a 10-year period and potential studies screened against eligibility criteria. Included studies were quality-appraised. Original participant quotes and author interpretations were extracted and coded thematically into NVivo. All study processes were conducted by two reviewers working independently with findings discussed with the wider team and key stakeholders. Studies were related by findings into clusters and translated reciprocally and refutationally to develop a new line-of-argument synthesis and conceptual model. Findings are reported using eMERGe guidance.

RESULTS

Fifteen papers (13 studies) conducted between 2007 and 2017 reporting the experiences of 336 doctors of varying seniority working in acute hospitals across seven countries, were synthesised. Study findings related in four ways which collectively represented multiple challenges to appropriate antibiotic medical prescribing in hospitals: loss of ownership of prescribing decisions, tension between individual care and public health concerns, evidence-based practice versus bedside medicine, and diverse priorities between different clinical teams. The resulting new line-of-argument and conceptual model reflected how these challenges operated on both micro- and macro-level, highlighting key areas for improving current prescribing practice, such as creating feedback mechanisms, normalising input from other specialties and reducing variation in responsibility for antibiotic decisions.

CONCLUSIONS

This first meta-ethnography of doctors` experiences of antibiotic prescribing in acute hospital settings has enabled development of a novel conceptual model enhancing understanding of appropriate antibiotic prescribing. That is, hospital antibiotic prescribing is a complex, context-dependent and dynamic process, entailing the balancing of many tensions. To change practice, comprehensive efforts are needed to manage failures in communication and information provision, promote distribution of responsibility for antibiotic decisions, and reduce fear of consequences from not prescribing.

TRIAL REGISTRATION

PROSPERO registration: CRD42017073740 .

Too Much Cancer Care?: Nurses' Perspectives on the Unnecessary Use of Oncology Services

BACKGROUND

"Unnecessary use of health services" refers to care that does not add value for patients and can lead to physical, emotional, and economical harm. High rates of overuse have been reported within oncology, and patients experience its consequences.

OBJECTIVE

The aim of this study was to explore perceptions and experiences of oncology nurses regarding unnecessary use of oncology services.

METHODS

In-depth, semistructured interviews were conducted with a convenience sample of 20 oncology nurses currently practicing in Israel. Interviews were recorded, transcribed, and analyzed thematically.

RESULTS

Themes included perceptions of unnecessary use of health services in cancer (causes and effects of unnecessary use, current and proposed solutions) and negative effects of unnecessary cancer care on patients, families, providers, and the system, including decreased quality of life, increased suffering, and emotional effects on patients and families. Causes were seen on provider, family, and patient levels, such as difficulty for providers to "give up," lack of registered nurses' authority, and family and patient demands. Multidisciplinary care provision, nurses' role, and the patient-provider relationship were seen as existing facilitators minimizing unnecessary use. Future improvement can be achieved by strengthening relationships, providing support to healthcare providers, and improving communication.

CONCLUSIONS

Nurses perceive unnecessary use of health services as a result of multiple, interlinked and complex causes, but few targeted interventions exist. Future research should explore quantifying unnecessary use to determine an accurate representation of the issue.

IMPLICATIONS FOR PRACTICE

Solutions should include engaging patients and families, involving nurses, and fostering multidisciplinary collaborative teamwork to positively affect care and treatment decision-making processes.

A behavioural approach to specifying interventions: what insights can be gained for the reporting and implementation of interventions to reduce antibiotic use in hospitals?

Background

Reducing unnecessary antibiotic exposure is a key strategy in reducing the development and selection of antibiotic-resistant bacteria. Hospital antimicrobial stewardship (AMS) interventions are inherently complex, often requiring multiple healthcare professionals to change multiple behaviours at multiple timepoints along the care pathway. Inaction can arise when roles and responsibilities are unclear. A behavioural perspective can offer insights to maximize the chances of successful implementation.

Objectives

To apply a behavioural framework [the Target Action Context Timing Actors (TACTA) framework] to existing evidence about hospital AMS interventions to specify which key behavioural aspects of interventions are detailed.

Methods

Randomized controlled trials (RCTs) and interrupted time series (ITS) studies with a focus on reducing unnecessary exposure to antibiotics were identified from the most recent Cochrane review of interventions to improve hospital AMS. The TACTA framework was applied to published intervention reports to assess the extent to which key details were reported about what behaviour should be performed, who is responsible for doing it and when, where, how often and with whom it should be performed.

Results

The included studies (n = 45; 31 RCTs and 14 ITS studies with 49 outcome measures) reported what should be done, where and to whom. However, key details were missing about who should act (45%) and when (22%). Specification of who should act was missing in 79% of 15 interventions to reduce duration of treatment in continuing-care wards.

Conclusions

The lack of precise specification within AMS interventions limits the generalizability and reproducibility of evidence, hampering efforts to implement AMS interventions in practice.

Antibiotic stewardship knowledge and belief differences among healthcare professionals in hospitals: A survey study

BACKGROUND

Collaborative practice in healthcare has been recommended to improve the quality of antimicrobial stewardship interventions, a behavioral change in antimicrobial use. Insufficient knowledge regarding antibiotic resistance, the fear of complications from infections, and how providers perceive antibiotic use and resistance are likely to influence prescribing behavior. This study's objective was to identify the knowledge and belief healthcare professionals' differences about antibiotic stewardship.

METHODS

This cross-sectional survey study of three hospitals in the East Java province, Indonesia utilized a 43-item questionnaire to assess antimicrobial stewardship knowledge and belief. There were 12 knowledge questions (total possible score: 12) and 31 belief questions (total possible score: 155). The Kuder Richardson 20 (KR-20) and Cronbach alpha values of the questionnaire were 0.54 and 0.92, respectively.

RESULTS

Out of the 257 respondents, 19% (48/257) had a low scores of knowledge, and 39% (101/257) had low scores on belief about antibiotic stewardship (101/257). Most midwives had a low scores on knowledge (25/61) and low scores on belief (46/61). Respondents with high scores on belief were 17% (10/59) physicians, 15% (4/27) pharmacists, 8% (5/65) nurses, and 3% (2/61) midwives.

CONCLUSION

Among healthcare professionals, knowledge and belief differences concerning antibiotic stewardship vary widely. These differences will affect their capability, behavior, and contribution to the healthcare team collaboration and performance. Further studies are needed to evaluate the correlation between the level of inter-professional collaboration and the quality of the antibiotic stewardship implementation.

Nurses and Antimicrobial Stewardship: Past, Present, and Future

Successful antimicrobial stewardship programs must be a truly collaborative multidisciplinary team effort. Nurses have critical contributions and are recognized more in publications about antimicrobial stewardship. Examination of patient care workflow patterns indicates the central role of nurses in the application of stewardship concepts in patient care. Education about antimicrobial resistance and antimicrobial stewardship is important not only for nurses and other health care providers but also for the general public. Analysis of the health care workforce population shows the importance of integrating this largest segment of health care providers in the routine daily care of patients into all stewardship efforts.

Reconsidering the nursing role in antimicrobial stewardship: a multisite qualitative interview study

OBJECTIVES

This study responds to calls for greater focus on nursing roles, and the need for nursing integration within the antimicrobial optimisation agenda. The objective of this study was to explore Australian hospital nurses' views on antimicrobial resistance and antimicrobial stewardship (AMS) in a hospital setting, in order to better understand the opportunities for and challenges to integration of nursing staff in antimicrobial optimisation within hospital settings.

DESIGN

Qualitative one-on-one, semistructured interviews. Interview transcripts were digitally audio-recorded and transcribed verbatim. Data were subject to thematic analysis supported by the framework approach and informed by sociological methods and theory.

SETTING

Four hospitals (three public and one private), across metropolitan, regional and remote areas, in two Australian states.

PARTICIPANTS

86 nurses (77 females, 9 males), from a range of hospital departments, at a range of career stages.

RESULTS

Findings were organised into three thematic domains: (1) the current peripheral role of nurses in AMS; (2) the importance of AMS as a collaborative effort, and current tensions around interprofessional roles and (3) how nurses can bolster antimicrobial optimisation within AMS and beyond.

CONCLUSION

Nursing staff are central to infection management within the hospital and are thus ideally located to enhance antibiotic optimisation and contribute to AMS governance. However, without increased interprofessional cooperation, education and integration in the AMS agenda, as well as addressing organisational/resource constraints in the hospital, the nursing role in stewardship will remain limited.

Nurse role and contribution to antimicrobial stewardship: An integrative review

AIM

To examine existing published literature regarding nurses and antimicrobial stewardship, and their potential role and contribution, to identify what is known, to evaluate methodologies used in published research, and to review and integrate findings to inform practice and future priorities for research.

DESIGN

Integrative review.

METHODOLOGY

The approach to this review was informed by Whittemore and Knafl's integrative review methodology. Electronic databases were searched for papers published since the start of the database to November 2019, with abstracts available, related to humans and published in English. Papers were included regardless of practice setting (acute, aged, and primary care) and if they were research based, included nurses as participants and reported specifically on results from nurses or that had implications for nursing practice. Excluded were conference abstracts, and papers focussed solely on nurse prescriber, nurse practitioner, or nurse manager roles.

RESULTS

Fifty-two papers were included in the review. Identified themes were: i) nursing knowledge, learning needs and education; ii) nurse perceptions of the nursing role and motivations for involvement; iii) nursing brokerage and influence on information flow to and from patients; iv) nursing workflow, workload and workarounds; and v) nurse leadership. Methodological quality of the included papers varied, limiting transferability and applicability of findings for some of the included studies.

CONCLUSION

Formal inclusion of nurses in antimicrobial stewardship activities has been associated with improved nurse knowledge, nurse confidence, and in some cases improved clinical outcomes for patients. The review reinforces nursing values as a motivator of nursing actions, and reveals the complex yet significant influence of nurses on antimicrobial prescribing. Potential opportunities to enhance nurses' participation and contribution to antimicrobial stewardship include; formal acknowledgement of the nurse role, educating nurses so that they are aware of how they can contribute, collaborating with nurses in planning and implementing local stewardship activities, and ensuring nurse leaders are involved. However, evidence on this topic remains limited. Research is needed to facilitate greater understanding about the nature, scope and influence of the nurse role in antimicrobial stewardship, how nurses enact and carry out their role, and nurses' support needs. Tweetable abstract: Integrative review explores #nurse role in #antimicrobialstewardship. Nurse contribution, influence significant, but not well understood.

The nurses' role in antimicrobial stewardship: A scoping review

BACKGROUND

The role of nurses in antimicrobial stewardship is understated and not well understood. Nurses can have a significant impact on the development of antimicrobial resistant bacteria in hospitals and the wider community through their management of intravenous antibiotics.

OBJECTIVE

To investigate the nurse's role in antimicrobial stewardship and examine best practice for preparing, administering and disposing of intravenous antibiotics.

METHODS

A systematically conducted scoping review was used. Seven databases were searched for published articles. Retrieved articles were screened for eligibility against pre-set inclusion and exclusion criteria with eligible full-text articles included in the synthesis. Reference lists of eligible articles and social media were reviewed to identify further sources of literature.

RESULTS

Forty-three sources of evidence were included. The extracted data indicate that a part of the nurse's role in antimicrobial stewardship is to monitor judicious antibiotic prescribing practices. Other than literature related to medication errors, there was limited research describing best practice when preparing, administering and disposing of intravenous antibiotics. There was also little evidence of consistent policy, guidelines and education for nurses' practice related to antimicrobial stewardship.

CONCLUSIONS

The evidence for best practice when nurses prepare, administer and dispose of intravenous antibiotics in hospitals is scarce. When nurses use best practice to manage intravenous antibiotics, the risk of antimicrobial resistant bacteria developing is minimised. The role of nurses in antimicrobial stewardship needs to be supported through education and evidence-based guidelines. Tweetable abstract: Nurse work practices may prevent the development and spread of antimicrobial resistant bacteria.

Empowerment of nurses in antibiotic stewardship: a social ecological qualitative analysis

BACKGROUND

Inappropriate antibiotics use and antimicrobial resistance (AMR) are increasingly becoming global health issues of great concern. Despite the established antibiotic stewardship programmes (ASPs) in many countries, limited efforts have been made to engage nurses and clearly define their roles in ASPs.

AIM

An exploratory qualitative study was conducted to understand the facilitators and barriers that impact nurses' involvement and empowerment in antibiotic stewardship.

METHODS

Focus group discussions (FGDs) were conducted with purposively sampled nurses from three major public hospitals in Singapore. FGDs were audio-recorded and transcribed verbatim. Data were analysed using Applied Thematic Analysis and interpreted using the Social Ecological Model.

FINDINGS

At the intrapersonal level, nurses felt empowered in carrying out their roles in antibiotic administration. They saw themselves as gatekeepers to ensure that the prescribed antibiotics were administered appropriately. However, nurses felt they lacked the knowledge and expertise in antibiotic use and AMR prevention. At the interpersonal level, this deficit in knowledge and expertise in antibiotic use impacted how they were perceived by patients and caregivers as well as their interactions with the primary care team when voicing outpatient safety concerns and antibiotic administration suggestions. At the organizational level, nurses relied on drug administration guidelines to ensure appropriate antibiotic administration and as a safety net when physicians questioned their clinical practice. At the community level, nurses felt there was a lack of awareness and knowledge on antibiotic use among the general population.

CONCLUSION

These findings provide important insights to harness the contributions of nurses, and to formally acknowledge and enlarge their roles in ASPs.

Self-Treatment with Antibiotics: Knowledge level, Prevalence and Indications for Practicing Among University Students in Jordan

BACKGROUND

Self-treatment with antibiotics involves obtaining medicines without a prescription, sharing medicines with members of one's social circle, or using leftover medicines stored at home.

OBJECTIVE

Assess the prevalence, knowledge level, reasons for practicing self-treatment of antibiotic among undergraduate university students.

METHODS

The study was conducted cross-sectional on a sample of 201 students. A pre-validated questionnaire called "self-treatment with antibiotics", containing 27 close-ended questions, was administered to each subject. Data were analyzed using SPSS version 16 and the results were expressed as counts and percentages.

RESULTS AND DISCUSSION

Knowledge about self-treatment with antibiotics was good in general, and health-related students had a better level of knowledge about self-treatment with antibiotics than non-health-related students. The majority of the participants had not used self-treatment with antibiotics. Gender, age, and the last time antibiotic taken affected self-treatment with antibiotics. The most common indication for self-treatment with antibiotics was flu, cold, and tonsillitis. The most common reason for practicing self-treatment with antibiotics was being considered as a convenient and rapid solution. Internet was the main source for university students regarding knowledge about antibiotic use and resistance.

CONCLUSION

Self-treatment with antibiotics is affected by several social and demographic variables, and the role of media, public policies, university curricula as well as physicians and pharmacists should be enforced and activated to eliminate inappropriate uses of antibiotics and to correct misconceptions that encourage self-treatment with antibiotics.

Perceived barriers to the development of the antimicrobial stewardship role of the nurse in intensive care: Views of healthcare professionals

Background

Antimicrobial stewardship has become an important initiative within intensive care units in the global fight against antimicrobial resistance. Support for nurses to participate in and actively direct antimicrobial stewardship interventions is growing however, there may be barriers that impede the development of this nursing role.

Objectives

To explore the views of healthcare professionals regarding barriers to the antimicrobial stewardship role of the nurse in intensive care in a private hospital in KwaZulu-Natal, South Africa.

Methods

Using a qualitative research approach, purposive sampling was used to identify fifteen participants from the disciplines of nursing, surgery, anaesthetics, internal medicine, microbiology, and pharmacy in a general intensive care unit. Content analysis was used to code data obtained from each individual interview.

Results

The following categories and subcategories were derived: regarding barriers to the role of the nurse in antimicrobial stewardship: (i) lack of collaboration (subcategories: not participating in the antimicrobial stewardship programme, no feedback about antimicrobial resistance in the unit, and not part of decision-making); (ii) inadequate knowledge (subcategories: not understanding infection prevention and control, missing the link between laboratory results and start of treatment, and poor knowledge of antibiotics and their administration); and (iii) inexperienced nurses (subcategories: shortage of intensive care nurses, lack of experienced nurses, and inadequate nursing staff to provide in-service training).

Conclusion

The nursing role within antimicrobial stewardship was negatively affected by both staffing and collaborative difficulties, which impacted on the implementation of antimicrobial stewardship within the unit.

Contributions of the study

Nurses are not well-integrated into antimicrobial stewardship. Insufficient training and education on aspects of antimicrobial stewardship are available to nurses.

Impact of medical professionals on Carbapenem-resistant Pseudomonas aeruginosa: moderating effect of workload based on the panel data in China

Background

Antimicrobial resistance (AMR), especially carbapenem-resistant Pseudomonas aeruginosa (CRPA), causes a serious increase in morbidity, mortality and costs. Medical professionals play an important role in curbing AMR. Previous studies overlooked the impact of workload on the relationship between medical professionals and AMR. This study aimed to explore the relationship between medical professionals and the CRPA rate as well as the moderating effect of medical professionals’ workload on this relationship.

Methods

A provincial-level panel dataset from 2014 to 2017 was constructed. Medical professionals were measured by the numbers of physicians, registered nurses, pharmacists, and clinical microbiologists per 1000 population. Workload was measured by the number of daily physician visits. Fixed effect model and hierarchical regression analysis were performed to explore the moderating effect of workload on medical professionals and the CRPA rate.

Results

The numbers of physicians, registered nurses, pharmacists and clinical technicians were significantly negative associated with the CRPA rate (coef. = − 0.889, − 0.775, − 1.176, and − 0.822; P = 0.003, 0.003, 0.011, and 0.007, respectively). Workload had a significant and positive moderating effect on physicians, registered nurses, pharmacists, clinical technicians and the CRPA rate (coef. = 1.270, 1.400, 2.210, and 1.634; P = 0.004, 0.001, 0.035, and 0.003, respectively).

Conclusions

Increasing the number of medical professionals may help curb the CRPA rate. Measures aimed at reducing medical professionals’ workload should be implemented to further improve CRPA performance.

Nursing Role for Medication Stewardship Within Long-Term Care Facilities

Elderly residents in long-term care facilities (LTCFs) constitute a population noted to have a large number of medications prescribed and administered. The aim of this article is to explore the nursing role for medication management, with an emphasis on antimicrobial stewardship, guided by disciplinary knowledge of King's theory of goal attainment and skill-based medication knowledge. The outcome is a nursing workforce truly engaged in working with interdisciplinary colleagues and focusing on care planning that includes medication management to improve the health status of residents in long-term care facilities.

Nurses as antimicrobial stewards: Recognition, confidence, and organizational factors across nine hospitals

BACKGROUND

There are national calls to engage nurses as antimicrobial stewards, but it is unknown how patient safety culture influences nurses' antimicrobial stewardship (AS) involvement.

METHODS

Cross-sectional survey to determine bedside nurses' recognition and performance confidence in AS. Nine hospitals ranged in size from 42 to 562 beds serving pediatric and adult populations in 2 different metropolitan areas. Composite scores for nursing practices, performance confidence, and organizational factors were developed and correlated. Analysis of variance (ANOVA) with Tukey HSD post-hoc tests and nonparametric (Kruskal-Wallis) tests with Bonferroni adjusted P values for multiple comparisons were used to evaluate differences by clinical unit and years of clinical experience. Free text comments were categorized by theme.

RESULTS

A total of 558 nurses participated (13% response rate). A significant positive association r_s = 0.454, P < .001 was found between nurses' beliefs about nursing practices that contribute to AS processes and their confidence to perform. Ninety one nurses provided comments with 50 statements indicating the primary barrier to stewardship were organizational factors including perceived lack of a safety culture.

CONCLUSIONS

Nurses identified a professional role in AS processes, though safety culture inhibited their involvement. These findings can help enhance the inclusion of nurses in AS efforts.

Nurse roles in antimicrobial stewardship: lessons from public sectors models of acute care service delivery in the United Kingdom

Background

Health care services must engage all relevant healthcare workers, including nurses, in optimal antimicrobial use to address the global threat of drug-resistant infections. Reflecting upon the variety of antimicrobial stewardship (AMS) nursing models already implemented in the UK could facilitate policymaking and decisions in other settings about context-sensitive, pragmatic nurse roles.

Methods

We describe purposefully selected cases drawn from the UK network of public sector nurses in AMS exploring their characteristics, influence, relations with clinical and financial structures, and role content.

Results

AMS nursing has been deployed in the UK within 'vertical', 'horizontal' or 'hybrid' models. The 'vertical' model refers to a novel, often unique consultant-type role ideally suited to transform organisational practice by legitimising nurse participation in antimicrobial decisions. Such organisational improvements may not be straightforward, though, due to scalability issues. The 'horizontal' model can foster coordinated efforts to increase optimal AMS behaviours in all nurses around a narrative of patient safety and quality. Such model may be unable to address tensions between the required institutional response to sepsis and the inappropriate use of antibiotics. Finally, the 'hybrid' model would increase AMS responsibilities for all nurses whilst allocating some expanded AMS skills to existing teams of specialists such as sepsis or vascular access nurses. This model can generate economies of scale, yet it may be threatened by a lack of clarity about a nurse-relevant vision.

Conclusions

A variety of models articulating the participation of nurses in antimicrobial stewardship efforts have already been implemented in public sector organisations in the UK. The strengths and weaknesses of each model need considering before implementation in other settings and healthcare systems, including precise metrics of success and careful consideration of context-sensitive, resource dependent and pragmatic solutions.

Optimizing carbapenem use through a national quality improvement programme

Background

Concern about increasing carbapenem and piperacillin/tazobactam use led the Scottish Antimicrobial Prescribing Group (SAPG) to develop national guidance on optimal use of these agents, and to implement a quality improvement programme to assess the impact of guidance on practice.

Objectives

To evaluate how SAPG guidance had been implemented by health boards, assess how this translated into clinical practice, and investigate clinicians' views and behaviours about prescribing carbapenems and alternative agents.

Methods

Local implementation of SAPG guidance was assessed using an online survey. A bespoke point prevalence survey was used to evaluate prescribing. Clinicians' experience of using carbapenems and alternatives was examined through semi-structured interviews. National prescribing data were analysed to assess the impact of the programme.

Results

There were greater local restrictions for carbapenems than for piperacillin/tazobactam. Laboratory result suppression was inconsistent between boards and carbapenem-sparing antibiotics were not widely available. Compliance with local guidelines was good for meropenem but lower for piperacillin/tazobactam. Indication for use was well documented but review/stop dates were poorly documented for both antibiotics. Decisions to prescribe a carbapenem were influenced by local guidelines and specialist advice. Many clinicians lacked confidence to de-escalate treatment. Use of both antibiotics decreased during the course of the programme.

Conclusions

A multifaceted quality improvement programme was used to gather intelligence, promote behaviour change, and focus interventions on the use of carbapenems and piperacillin/tazobactam. Use of these antimicrobials decreased during the programme-a trend not seen elsewhere in Europe. The programme could be generalized to other antimicrobials.

Diagnostic Bacteriology in District Hospitals in Sub-Saharan Africa: At the Forefront of the Containment of Antimicrobial Resistance

This review provides an update on the factors fuelling antimicrobial resistance and shows the impact of these factors in low-resource settings. We detail the challenges and barriers to integrating clinical bacteriology in hospitals in low-resource settings, as well as the opportunities provided by the recent capacity building efforts of national laboratory networks focused on vertical single-disease programmes. The programmes for HIV, tuberculosis and malaria have considerably improved laboratory medicine in Sub-Saharan Africa, paving the way for clinical bacteriology. Furthermore, special attention is paid to topics that are less familiar to the general medical community, such as the crucial role of regulatory frameworks for diagnostics and the educational profile required for a productive laboratory workforce in low-resource settings. Traditionally, clinical bacteriology laboratories have been a part of higher levels of care, and, as a result, they were poorly linked to clinical practices and thus underused. By establishing and consolidating clinical bacteriology laboratories at the hospital referral level in low-resource settings, routine patient care data can be collected for surveillance, antibiotic stewardship and infection prevention and control. Together, these activities form a synergistic tripartite effort at the frontline of the emergence and spread of multi-drug resistant bacteria. If challenges related to staff, funding, scale, and the specific nature of clinical bacteriology are prioritized, a major leap forward in the containment of antimicrobial resistance can be achieved. The mobilization of resources coordinated by national laboratory plans and interventions tailored by a good understanding of the hospital microcosm will be crucial to success, and further contributions will be made by market interventions and business models for diagnostic laboratories. The future clinical bacteriology laboratory in a low-resource setting will not be an "entry-level version" of its counterparts in high-resource settings, but a purpose-built, well-conceived, cost-effective and efficient diagnostic facility at the forefront of antimicrobial resistance containment.

Decisional issues in antibiotic prescribing in French nursing homes: An ethnographic study

Background:Medication prescription is generally the responsibility of doctors. In nursing homes, the nursing staff is often the first to suspect an infection. Today, physicians are more confident with nursing assessment, relying primarily on nursing staff information. Very few studies have investigated the nurses' influence on decision of medical prescription. This study investigates the role of nurses in antibiotic prescribing for the treatment of suspected infections in nursing home residents. Design and methods:An ethnographic study based on semi-structured interviews and participant observations was conducted. Sixteen nurses and five doctors working in five nursing homes in Paris, France participated between October 2015 and January 2016. Results:Given their proximity to elderly residents, registered nurses at the nursing homes occasionally assisted doctors in their medical diagnostic. However, nurses who are theoretically incompetent have met difficulties in their ability to participate in their decisions to prescribe antibiotics when managing residents' infections. Conclusion: if proximity and nursing skills reinforce the relevance of the clinical judgment of nurses, the effective and collaborative communication between the nurse and the doctor may help the nurse to enhance their role in the antibiotic prescribing in nursing homes, which would enhance antimicrobial stewardship efficiency.

Snapshot of antimicrobial stewardship programs in the hospitals of Pakistan: findings and implications

Objective

We are unaware of the extent of antimicrobial stewardship programs (ASPs) among hospitals in Pakistan, which is a concern given the population size, high use of antibiotics across sectors and increasing antimicrobial resistance (AMR) rates. Consequently, we sought to address this by undertaking a comprehensive survey.

Method

In this cross-sectional observational study in Punjab, an instrument of the measure was developed based on health care facility characteristics and ASPs after an extensive literature review. The questionnaire was circulated by mail or through drop off surveys to medical superintendents or directors/heads of pharmacy departments of hospitals.

Results

Out of 254, a total of 137 hospitals fully completed the questionnaire - 11 primary, 65 secondary, 46 tertiary and 15 specialized hospitals. The use of antimicrobial prescribing guidelines (68.7%), provision of infectious diseases consultation services (66.4%), clinical pharmacy service (65.7%), use of drug and therapeutics committees to approve antimicrobial prescribing (65.5%), regular audit by doctors on antimicrobial prescribing (54.1%) and use of a restricted formulary for antimicrobial (50.4%) were the most common ASPs. However, most of these activities were only somewhat or moderately successful. Whereas, electronic antimicrobial prescribing approval systems (15.3%), using a sticker to notify prescribers regarding the need to obtain approval for the antimicrobial prescribed (16.1%) and participation in the national antimicrobial utilization surveillance program (19.7%) were only seen in a few hospitals.

Conclusion

Study inferred that there are inadequate ASPs in the hospitals of Pakistan. A multidisciplinary approach, clinical leadership and availability of motivated and trained individuals are essential elements for the success of future ASPs.

Knowledge and Practices of Physicians and Nurses Related to Urine Cultures in Catheterized Patients: An Assessment of Adherence to IDSA Guidelines

Background

A positive urine culture often drives initiation of antimicrobials even in the absence of symptoms. Our objectives were to evaluate the knowledge and practice patterns related to ordering urine cultures in patients with indwelling urinary catheters.

Methods

We performed chart reviews of catheter-associated urinary tract infections (CAUTIs) at our academic health care system between October 1, 2015, and September 30, 2017, to assess practice patterns related to the assessment of potential CAUTIs. Following this, we surveyed physicians and nurses about indications for ordering urine cultures in catheterized patients between January 11, 2018, and April 17, 2018. The accuracy of these indications was assessed based on Infectious Diseases Society of America CAUTI and asymptomatic bacteriuria guidelines.

Results

On chart review, we identified 184 CAUTIs in 2 years. In 159 episodes (86%), urine cultures were ordered inappropriately. In 114 episodes (62%), CAUTI criteria were met by “pan-culturing” rather than symptom-directed testing. Twenty cases (11%) experienced partial or delayed management of other infections, drug adverse events, and Clostridioides difficile infections (CDIs). On our survey, we received 405 responses, for a response rate of 45.3%. Mean scores varied by occupation and level of training. Nurses were more likely than physicians to consider change in appearance (61% vs 23%; P < .05) and odor (74% vs 42%; P < .05) of urine as indications to order urine cultures.

Conclusions

Our data reveal specific knowledge gaps among physicians and nurses related to ordering urine cultures in catheterized patients. The practice of pan-culturing and inappropriate urine culture orders may contribute to overdiagnosis of surveillance CAUTIs, delay in diagnosis of alternative infections, and excess CDIs.

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

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

Education and management of antimicrobials amongst nurses in Africa-a situation analysis: an Infection Control Africa Network (ICAN)/BSAC online survey

Objectives

To assess the current involvement of nurses in the use and management of antimicrobials and their training in antimicrobial stewardship (AMS) across Africa.

Methods

After a pilot study, an online questionnaire (SurveyMonkey) in both French and English was circulated via the Infection Control Africa Network (ICAN) mailing list to both members and non-members in Africa. The study was conducted from 26 May to 19 August 2016. Data were summarized in proportions and bar charts; proportions were compared using the χ2 test. A multivariate logistic regression model was built to identify independent factors associated with the practice of AMS.

Results

While 96% of the 173 respondents were aware of the term 'AMS', 88.5% (146/165) undertook AMS tasks as part of their job; 91.9% (158/172) wanted to be more involved in AMS but 44.9% (71/158) reported there were barriers in doing so. AMS training was delivered to 36.7% (62/169) and 53.6% (90/168), respectively, during their undergraduate and postgraduate education. AMS training for healthcare workers in their institutions was reported by 50.3% (86/171), including training aimed at doctors (56.9%), pharmacists (76.7%), microbiologists (31.4%) and nurses (95.3%). However, 95.4% (164/172) of respondents asked for further education on AMS and the majority preferred AMS training to be part of the infection prevention curriculum (IPC) education. Three-quarters of institutions had an AMS initiative, but only ∼41% reported having seen a national AMS guideline.

Conclusions

For Africa, we recommend AMS education at undergraduate level, AMS policies at institution and national levels and incorporating AMS training into the IPC for nurses.

Antimicrobial stewardship and infection prevention and control in atopic dermatitis in children

Atopic dermatitis is a chronic, recurrent inflammatory skin disease, characterized by frequent exacerbations that can necessitate increased antibiotic use. A qualitative study was conducted at a specialist pediatric hospital to explore the perceptions of dermatology nurses on their role in antimicrobial stewardship when caring for children with atopic dermatitis. Thematic and content analysis derived that the awareness of nurses on antimicrobial stewardship was low, although they were implementing key elements in their clinical practice.

Antimicrobial stewardship and the hospital nurse and midwife: how do they perceive their role?

OBJECTIVES

Our aim was to determine the views of nurses and midwives in an acute hospital regarding a potential role in an antimicrobial stewardship programme.

METHODS

An online survey about antimicrobial stewardship was distributed to nursing and midwifery staff at the Royal Cornwall Hospitals NHS Trust. Descriptive statistics were used for analysis.

RESULTS

Eighty responses were received. Forty-three (54%) claimed to have heard the term antimicrobial stewardship. Only seven (9%) had cause to look at the hospital's antimicrobial guidelines at least once a week. Between 47 (60%) and 68 (87%) respondents agreed they should be involved in a range of stewardship roles. Constraints of time and workload, lack of knowledge and lack of adequate staff training were the three main perceived challenges to a wider role.

CONCLUSIONS

Staff in this survey recognise the potential for wider antimicrobial stewardship roles. They also identify challenges to undertaking these roles. Some of these barriers could be overcome by provision of education and support; hospital pharmacists may be able to assist with this role development.

Exploring community healthcare providers' perceptions on antimicrobial resistance

OBJECTIVES

Antimicrobial resistance (AMR) is a threat to global health, making previously curable diseases disabling or incurable. Human misuse of antimicrobials exacerbates the issue. As stewards to the public and prescribers of antimicrobials, healthcare providers are vital to reducing AMR, thus their perceptions and experiences around the issue must be explored. This study aimed to understand the perceptions of community nurses and physicians regarding the causes of AMR as well as barriers and facilitators to addressing it.

METHODS

In-depth, semi-structured interviews were conducted to understand the perceptions of nurses and physicians on these issues.

RESULTS

Overall, participants expressed that both environmental and human causes at various levels contribute to AMR. Whilst most themes were discussed by both healthcare practitioner groups, nurses more frequently mentioned patient causes and patient education compared with physicians. Participants also reflected on facilitators to reduce AMR, including guidelines, patient and provider education, and top-down and bottom-up initiatives. Identified barriers included patient demands, physician pressures and fears, and systemic overworking of physicians.

CONCLUSION

This study demonstrated numerous factors underpinning AMR and many barriers to addressing it, hence a multifaceted approach is required. This work also offers insight on how different groups can be utilised or will react to interventions.

Implementation of antibiotic stewardship in different settings - results of an international survey

Background

Antibiotic stewardship interventions are being implemented across different healthcare settings. We report the findings of a global survey of healthcare professionals on the implementation of antibiotic stewardship programmes.

Methods

Learners of a Massive Online Open Course (MOOC) on antibiotic stewardship were invited to complete an online survey on the core available organisational resources for stewardship. The categorical variables were analysed using chi-squared test, and Likert questions were analysed using an ordinal regression model. The p-values were considered as two-tailed. Significance was set at p-value of < 0.05.

Results

The response rate was 55% (505/920), from 53 countries. The responders were 36% (182) doctors, 26% (130) pharmacists, 18% (89) nurses and 20% (104) other (researchers, students and members of the public). Post-graduate training in infection management and stewardship was reported by 56% of doctors compared with 43% (OR 0.59, 95%CI 0.35–1.00) nurses and 35% (OR 0.39, 95%CI 0.24–0.62) of pharmacists. Hospitals were significantly (83% in teaching hospitals, 79% in regional hospitals, p = < 0.01) more likely to have antibiotic policies, when compared to primary care. A surveillance mechanism for antibiotic consumption was reported in 58% (104/178) of teaching hospitals and 62% (98/159) of regional hospitals. Antimicrobial resistance, patient needs, policy, peer influence and specialty level culture and practices were deemed important determinants for decision-making.

Conclusion

Postgraduate training and support in antibiotic prescribing remains low amongst nurses and pharmacists. Whilst antibiotic policies and committees are established in most institutions, surveillance of antibiotic use is not. The impact of specialty level culture, and peer influence appears to be important factors of antibiotic prescribing.

Antibiotic Resistance Policy and the Stewardship Role of the Nurse

Government policy, at all levels, should reflect current scientific evidence to curb the spread of multidrug-resistant organisms (MDROs) and to promote healthier lives for citizens and the global community. The World Health Organization estimates that approximately 63,000 Americans die annually of infections from MDROs. Annual spending in the United States used to combat MDRO infections surpassed $35 billion in 2015. This article is a review of U.S. policy regarding MDROs and focuses on several means with which nurses can implement antibiotic stewardship within their practices to stall the creation and global spread of antibiotic-resistant organisms. Nurses are vital to successfully implementing methods of antibiotic stewardship as they are at the center of multidisciplinary health care teams and have the greatest direct patient contact of all members within the team. Methods of antibiotic stewardship include limiting the use of antibiotics within animal husbandry industries, promotion of health care policy in line with antibiotic stewardship standards, and adopting more stringent clinical prescribing practices of antibiotics used in human therapies. Application of these improvements to U.S. federal, state, and local facility policies is in line with current scientific evidence and will provide a framework for cohesive partnerships with nations and institutions abroad that also struggle with the spread of MDROs in their own communities.

Communication strategies for improving public awareness on appropriate antibiotic use: Bridging a vital gap for action on antibiotic resistance

Antimicrobial resistance (AMR) is now a global public health issue and is projected to affect the longevity of people and increase health expenditure of countries. Its impact is going to be higher in low-middle income countries as the healthcare systems are suboptimal and ill-equipped to deal with the issue. As antibiotic misuse is the primary driver for AMR, there is an acute need to create awareness among general public regarding antibiotic misuse. This calls for a comprehensive communication strategy, which takes into account the various drivers of AMR and the solutions associated with it. In the short term, the focus of communication strategies can be on raising awareness in specific interest groups. It can help in channeling limited resources to achieve specific objectives for raising awareness among these groups, thereby improving the chances of behavior change. The general public can be targeted at a later stage or as a second phase with definite strategies and messages. But, it is erroneous to assume that a higher level of awareness will translate into a positive change in behavior. We propose that behavior change is the final fruit of a long and dynamic process. This process should rest on four pillars: adequate awareness, robust regulatory environment, emotional or material incentives, and an enabling social structure. Unless all these domains are satisfactorily addressed, the communication strategy will not be able to bring about a discernible change in behavior in terms of antibiotic use.

A theory-informed assessment of the barriers and facilitators to nurse-driven antimicrobial stewardship

BACKGROUND

Nurses represent an underused workforce for performing antimicrobial stewardship (AMS) activities. Before engaging nurses in these activities, barriers and facilitators to the targeted behavior change should be identified using a validated model.

METHODS

This was a prospective, qualitative, descriptive study to determine the barriers and facilitators to the promotion of intravenous (IV) to oral (PO) antimicrobials by nurses. Semi-structured 1-on-1 interviews of nurses were conducted from January-February 2017. Interviews were analyzed for themes within the domains of the theoretical domains framework (TDF) by directed-content analysis.

RESULTS

Evaluation of the 14 TDF domains revealed 9 modifiable barriers to nurse promotion of IV to PO step-down, including insufficient knowledge, lack of prescriber cooperation, lack of self-confidence, and low priority activity. Nine facilitators that could enhance nurse promotion of step-down were identified, including capability to assess patients for step-down, ability to communicate assessment results to the team, and preexistence of a variety of resources available for nurse education and training. Nurses perceived that increased step-down rates would increase nursing efficiency.

CONCLUSIONS

Nurses have the potential to improve AMS through promotion of IV to PO step-down of antimicrobials. Themes pertaining to barriers and facilitators of nurses' participation in IV to PO step-down of antimicrobials were identified.

Expanding Existing Antimicrobial Stewardship Programs in Pediatrics: What Comes Next

The prevalence of pediatric antimicrobial stewardship programs (ASPs) is increasing in acute care facilities across the United States. Over the past several years, the evidence base used to inform effective stewardship practices has expanded, and regulatory interest in stewardship programs has increased. Here, we review approaches for established, hospital-based pediatric ASPs to adapt and report standardized metrics, broaden their reach to specialized populations, expand to undertake novel stewardship initiatives, and implement rapid diagnostics to continue their evolution in improving antimicrobial use and patient outcomes.

Integrating staff nurses in antibiotic stewardship: Opportunities and barriers

BACKGROUND

Nursing has been called for greater participation in antibiotic stewardship. Although many of the functions that are integral to successful stewardship are within the scope of bedside nurses, data evaluating nursing engagement in stewardship are limited. The objective of this study was to identify nurses' roles and confidence in engaging in stewardship practices by conducting a survey of pediatric staff nurses employed at a 354-bed freestanding children's hospital with a well-established prospective audit and feedback stewardship program.

METHODS

An investigator-developed online survey was used to assess 10 identified practices that fall within the responsibility of inpatient nurses and contribute to the stewardship process.

RESULTS

One hundred and eighty nurses participated in the study. Nurses were highly confident assessing for an adverse drug reaction history, obtaining cultures prior to antibiotics, and participating in patient education. They were less confident in reviewing microbiology results to determine antibiotic appropriateness. Clinical practice and hospital culture influenced perceptions of the nursing role in stewardship. Reported barriers to stewarding included nurses not included in rounds, interdisciplinary power differentials, and nursing input not actively sought.

CONCLUSIONS

Barriers to nurse engagement were identified and could be addressed by improving education in microbiology and principles of antibiotic use along with more consistent inclusion of nurses in bedside rounds while also cultivating an environment where nurse contribution is actively sought.

Effective infection prevention and control: the nurse's role

Healthcare-associated infections and antimicrobial resistance are significant threats to public health. As resistant organisms continue to emerge and evolve, and antimicrobial agents become less effective, infection prevention and control remains a vital aspect of maintaining public health, particularly among vulnerable patient groups such as older people and young children. Because of the increasing complexity of healthcare treatments and interventions, patients are becoming increasingly susceptible to healthcare-associated infections and resistant organisms. This article outlines some of the challenges that nurses may experience in ensuring effective infection prevention and control, and how these can be addressed.

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

Background

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

Methods

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

Results

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

Conclusions

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