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Williams J, Chawraingern S, Degeling C. Distributive justice and value trade-offs in antibiotic use in aged care settings. Monash Bioeth Rev 2024:10.1007/s40592-024-00191-5. [PMID: 38990508 DOI: 10.1007/s40592-024-00191-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2024] [Indexed: 07/12/2024]
Abstract
Residential aged care facilities (RACF) are sites of high antibiotic use in Australia. Misuse of antimicrobial drugs in RACF contributes to antimicrobial resistance (AMR) burdens that accrue to individuals and the wider public, now and in the future. Antimicrobial stewardship (AMS) practices in RACF, e.g. requiring conformation of infection, are designed to minimise inappropriate use of antibiotics. We conducted dialogue groups with 46 participants with a parent receiving aged care to better understand families' perspectives on antibiotics and care in RACF. Participants grappled with value trade offs in thinking about their own parents' care, juggling imagined population and future harms with known short term comfort of individuals and prioritising the latter. Distributive justice in AMR relies on collective moral responsibility and action for the benefit of future generations and unknown others. In RACF, AMS requires value trade-offs and compromise on antimicrobial use in an environment that is heavily reliant on antimicrobial drugs to perform caring functions. In the context of aged care, AMS is a technical solution to a deeply relational and socio-structural problem and there is a risk that carers (workers, families) are morally burdened by system failures that are not addressed in AMS solutions.
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Affiliation(s)
- Jane Williams
- Australian Centre for Health Engagement, Evidence and Values (ACHEEV), School of Health and Society, University of Wollongong, Wollongong, Australia.
- Sydney Health Ethics, School of Public Health, The University of Sydney, Sydney, Australia.
| | - Sittichoke Chawraingern
- Australian Centre for Health Engagement, Evidence and Values (ACHEEV), School of Health and Society, University of Wollongong, Wollongong, Australia
| | - Chris Degeling
- Australian Centre for Health Engagement, Evidence and Values (ACHEEV), School of Health and Society, University of Wollongong, Wollongong, Australia
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Singh S, Degeling C, Drury P, Montgomery A, Caputi P, Deane FP. Nurses' Anxiety Mediates the Relationship between Clinical Tolerance to Uncertainty and Antibiotic Initiation Decisions in Residential Aged-Care Facilities. Med Decis Making 2024; 44:415-425. [PMID: 38532728 PMCID: PMC11102643 DOI: 10.1177/0272989x241239871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 02/06/2024] [Indexed: 03/28/2024]
Abstract
HIGHLIGHTS The impact of non-clinical factors (e.g., resident and family preferences) on prescribing is well-established. There is a gap in the literature regarding the mechanisms through which these preferences are experienced as pressure by prescribers within the unique context of residential aged-care facilities (RACFs).A significant relationship was found between nurses' anxiety, clinical tolerance of uncertainty, and the perceived need for antibiotics and assessment.As such, there is a need to expand stewardship beyond education alone to include interventions that help nurses manage uncertainty and anxiety and include other stakeholders (e.g., family members) when making clinical decisions in the RACF setting.
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Affiliation(s)
- Saniya Singh
- School of Psychology, University of Wollongong, Wollongong, NSW, Australia
- Australian Centre for Health Engagement, Evidence and Values, School of Health and Society, University of Wollongong, Wollongong NSW, Australia
| | - Chris Degeling
- Australian Centre for Health Engagement, Evidence and Values, School of Health and Society, University of Wollongong, Wollongong NSW, Australia
| | - Peta Drury
- School of Nursing, University of Wollongong, Wollongong NSW, Australia
| | - Amy Montgomery
- School of Nursing, University of Wollongong, Wollongong NSW, Australia
| | - Peter Caputi
- School of Psychology, University of Wollongong, Wollongong, NSW, Australia
| | - Frank P. Deane
- School of Psychology, University of Wollongong, Wollongong, NSW, Australia
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Jokanovic N, Lee SJ, Haines T, Hilmer SN, Jeon YH, Travis L, Ayton D, Watson E, Tsindos T, Stewardson AJ, Stuart RL, Cheng AC, Peel TN, Peleg AY. Pilot study to evaluate the need and implementation of a multifaceted nurse-led antimicrobial stewardship intervention in residential aged care. JAC Antimicrob Resist 2024; 6:dlae016. [PMID: 38371999 PMCID: PMC10873136 DOI: 10.1093/jacamr/dlae016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 01/12/2024] [Indexed: 02/20/2024] Open
Abstract
Objectives To evaluate the need and feasibility of a nurse-led antimicrobial stewardship (AMS) programme in two Australian residential aged care homes (RACHs) to inform a stepped-wedged, cluster randomized controlled trial (SW-cRCT). Methods A mixed-methods pilot study of a nurse-led AMS programme was performed in two RACHs in Victoria, Australia (July-December 2019). The AMS programme comprised education, infection assessment and management guidelines, and documentation to support appropriate antimicrobial use in urinary, lower respiratory and skin/soft tissue infections. The programme was implemented over three phases: (i) pre-implementation education and integration (1 month); (ii) implementation of the intervention (3 months); and (iii) post-intervention evaluation (1 month). Baseline RACH and resident data and weekly infection and antimicrobial usage were collected and analysed descriptively to evaluate the need for AMS strategies. Feedback on intervention resources and implementation barriers were identified from semi-structured interviews, an online staff questionnaire and researcher field notes. Results Six key barriers to implementation of the intervention were identified and used to refine the intervention: aged care staffing and capacity; access to education; resistance to practice change; role of staff in AMS; leadership and ownership of the intervention at the RACH and organization level; and family expectations. A total of 61 antimicrobials were prescribed for 40 residents over the 3 month intervention. Overall, 48% of antibiotics did not meet minimum criteria for appropriate initiation (respiratory: 73%; urinary: 54%; skin/soft tissue: 0%). Conclusions Several barriers and opportunities to improve implementation of AMS in RACHs were identified. Findings were used to inform a revised intervention to be evaluated in a larger SW-cRCT.
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Affiliation(s)
- Natali Jokanovic
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Sue J Lee
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Terry Haines
- School of Primary and Allied Health Care, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Sarah N Hilmer
- Departments of Clinical Pharmacology and Aged Care, Kolling Institute of Medical Research, Royal North Shore Hospital, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Yun-Hee Jeon
- Sydney Nursing School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Laura Travis
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Darshini Ayton
- Health and Social Care Unit, School of Public Health and Preventive Medicine, Monash University, Clayton Victoria, Australia
| | - Eliza Watson
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Tess Tsindos
- Health and Social Care Unit, School of Public Health and Preventive Medicine, Monash University, Clayton Victoria, Australia
| | - Andrew J Stewardson
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Rhonda L Stuart
- Public Health and Infection Prevention, Monash Health, Monash Medical Centre, Clayton, Victoria, Australia
| | - Allen C Cheng
- Monash Infectious Diseases, Monash Health, Monash Medical Centre, Clayton, Victoria, Australia
| | - Trisha N Peel
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Anton Y Peleg
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Monash Biomedicine Discovery Institute, Infection and Immunity Theme, Department of Microbiology, Monash University, Clayton, Victoria, Australia
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Bos M, Schouten J, De Bot C, Vermeulen H, Hulscher M. A hidden gem in multidisciplinary antimicrobial stewardship: a systematic review on bedside nurses' activities in daily practice regarding antibiotic use. JAC Antimicrob Resist 2023; 5:dlad123. [PMID: 38021036 PMCID: PMC10667038 DOI: 10.1093/jacamr/dlad123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 11/02/2023] [Indexed: 12/01/2023] Open
Abstract
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.
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Affiliation(s)
- Maria Bos
- School of Social Work and Health, Avans University of Applied Sciences, ’s Hertogenbosch, The Netherlands
- Scientific Center for Quality of Healthcare (IQ Healthcare), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jeroen Schouten
- Scientific Center for Quality of Healthcare (IQ Healthcare), Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Cindy De Bot
- School of Social Work and Health, Avans University of Applied Sciences, ’s Hertogenbosch, The Netherlands
| | - Hester Vermeulen
- Scientific Center for Quality of Healthcare (IQ Healthcare), Radboud University Medical Center, Nijmegen, The Netherlands
- School of Health, HAN University of Applied Sciences, Nijmegen, The Netherlands
| | - Marlies Hulscher
- Scientific Center for Quality of Healthcare (IQ Healthcare), Radboud University Medical Center, Nijmegen, The Netherlands
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Smit CCH, Rogers K, Robertson H, Taxis K, Pont LG. Real-World Data about Commonly Used Antibiotics in Long-Term Care Homes in Australia from 2016 to 2019. Antibiotics (Basel) 2023; 12:1393. [PMID: 37760690 PMCID: PMC10525936 DOI: 10.3390/antibiotics12091393] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 08/18/2023] [Accepted: 08/30/2023] [Indexed: 09/29/2023] Open
Abstract
In this study, we use real-world data to explore trends in antibiotic use in a dynamic cohort of long-term care (LTC) residents. A cross-sectional retrospective analysis of pharmacy medication supply records of 3459 LTC residents was conducted from 31 May 2016 to 31 May 2019. The primary outcome was the monthly prevalence of residents with an antibiotic episode. Secondary outcomes were the type of antibiotic used and duration of use. Over the three-year study period, residents were supplied 10460 antibiotics. On average, 18.9% of residents received an antibiotic monthly. Antibiotic use decreased slightly over time with a mean of 168/1000 (95% CI 146-177) residents using at least one antibiotic per month in June 2016 to 148/1000 (95% CI 127-156) in May 2019. The total number of antibiotic days per 100 resident days remained relatively constant over the study period: 8.8 days in 2016-2017, 8.4 in 2017-2018 and 6.4 in 2018-2019. Prolonged durations exceeding 100 days were seen for a small percentage of residents. We found extensive antibiotic use, which is a recognized contributor to antimicrobial resistance development, underscoring the necessity for quality treatment guidelines in this vulnerable population.
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Affiliation(s)
- Chloé C. H. Smit
- Graduate School of Health, University of Technology Sydney, Sydney, NSW 2008, Australia
| | - Kris Rogers
- Graduate School of Health, University of Technology Sydney, Sydney, NSW 2008, Australia
| | - Hamish Robertson
- School of Public Health & Social Work, Queensland University of Technology, Brisbane, QLD 4000, Australia
| | - Katja Taxis
- Department of PharmacoTherapy, Epidemiology and Economics, Faculty of Science and Engineering, University of Groningen, 9713 AV Groningen, The Netherlands
| | - Lisa G. Pont
- Graduate School of Health, University of Technology Sydney, Sydney, NSW 2008, Australia
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Tropea J, Peters S, Francis JJ, Bennett N, Fetherstonhaugh D, Buising K, Lim LL, Marshall C, Flynn M, Murray M, Yates P, Aboltins C, Johnson D, Kwong J, Long K, McCahon J, Lim WK. IMpleMenting Effective infection prevention and control in ReSidential aged carE (IMMERSE): protocol for a multi-level mixed methods implementation study. BMC Geriatr 2023; 23:109. [PMID: 36823588 PMCID: PMC9948775 DOI: 10.1186/s12877-023-03766-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 01/19/2023] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND Older people living in residential aged care facilities are at high risk of acquiring infections such as influenza, gastroenteritis, and more recently COVID-19. These infections are a major cause of morbidity and mortality among this cohort. Quality infection prevention and control practice in residential aged care is therefore imperative. Although appointment of a dedicated infection prevention and control (IPC) lead in every Australian residential aged care facility is now mandated, all people working in this setting have a role to play in IPC. The COVID-19 pandemic revealed inadequacies in IPC in this sector and highlighted the need for interventions to improve implementation of best practice. METHODS Using mixed methods, this four-phase implementation study will use theory-informed approaches to: (1) assess residential aged care facilities' readiness for IPC practice change, (2) explore current practice using scenario-based assessments, (3) investigate barriers to best practice IPC, and (4) determine and evaluate feasible and locally tailored solutions to overcome the identified barriers. IPC leads will be upskilled and supported to operationalise the selected solutions. Staff working in residential aged care facilities, residents and their families will be recruited for participation in surveys and semi-structured interviews. Data will be analysed and triangulated at each phase, with findings informing the subsequent phases. Stakeholder groups at each facility and the IMMERSE project's Reference Group will contribute to the interpretation of findings at each phase of the project. DISCUSSION This multi-site study will comprehensively explore infection prevention and control practices in residential aged care. It will inform and support locally appropriate evidence-based strategies for enhancing infection prevention and control practice.
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Affiliation(s)
- Joanne Tropea
- Department of Aged Care, Royal Melbourne Hospital, Level 8 CRM, 300 Grattan Street, Parkville, VIC, 3050, Australia. .,Department of Medicine - Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, 3010, Australia.
| | - Sanne Peters
- grid.1008.90000 0001 2179 088XSchool of Health Sciences, University of Melbourne, Parkville, VIC 3010 Australia ,grid.5596.f0000 0001 0668 7884Department of Public Health and Primary Care, University of Leuven, KU Leuven, Louvain, Belgium
| | - Jill J. Francis
- grid.1008.90000 0001 2179 088XSchool of Health Sciences, University of Melbourne, Parkville, VIC 3010 Australia ,grid.1055.10000000403978434Department of Health Services Research, Peter MacCallum Cancer Centre, Melbourne, VIC 3000 Australia ,grid.1008.90000 0001 2179 088XDepartment of Oncology, Sir Peter MacCallum, University of Melbourne, Parkville, VIC 3010 Australia ,grid.412687.e0000 0000 9606 5108Ottawa Hospital Research Institute – General Campus, Centre for Implementation Research, 501 Smyth Road, Ottawa, ON K1H 8L6 Canada
| | - Noleen Bennett
- grid.1008.90000 0001 2179 088XVictorian Healthcare Associated Infection Surveillance System (VICNISS) Coordinating Centre and Department of Infectious Diseases, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne VIC 3000, Australia ,grid.1008.90000 0001 2179 088XDepartment of Infectious Diseases, National Centre for Antimicrobial Stewardship, University of Melbourne, Melbourne, VIC 3000 Australia ,grid.1008.90000 0001 2179 088XDepartment of Nursing, School of Health Sciences, University of Melbourne, Parkville, VIC 3010 Australia
| | - Deirdre Fetherstonhaugh
- grid.1018.80000 0001 2342 0938Australian Centre for Evidence Based Aged Care (ACEBAC), La Trobe University, Bundoora, VIC 3086 Australia
| | - Kirsty Buising
- grid.416153.40000 0004 0624 1200Victorian Infectious Diseases Service, Royal Melbourne Hospital, Parkville, VIC 3050 Australia ,grid.1008.90000 0001 2179 088XDepartment of Infectious Diseases, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne VIC 3000, Australia
| | - Lyn-li Lim
- grid.1008.90000 0001 2179 088XVictorian Healthcare Associated Infection Surveillance System (VICNISS) Coordinating Centre and Department of Infectious Diseases, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne VIC 3000, Australia
| | - Caroline Marshall
- grid.1008.90000 0001 2179 088XDepartment of Infectious Diseases, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne VIC 3000, Australia ,grid.416153.40000 0004 0624 1200Infection Prevention and Surveillance Service, Royal Melbourne Hospital, Parkville, VIC 3050 Australia
| | - Madelaine Flynn
- Director of Infection Prevention, Northern Health, Epping, VIC 3076 Australia ,Victorian Aged Care Response Centre, Australian Department of Health, Melbourne VIC 3000, Australia
| | - Michael Murray
- grid.1018.80000 0001 2342 0938Australian Centre for Evidence Based Aged Care (ACEBAC), La Trobe University, Bundoora, VIC 3086 Australia ,grid.410678.c0000 0000 9374 3516Department of Geriatric Medicine, Austin Health, Heidelberg, VIC 3084 Australia ,grid.1008.90000 0001 2179 088XDepartment of Medicine – Austin Health, University of Melbourne, Heidelberg, VIC 3084 Australia
| | - Paul Yates
- grid.410678.c0000 0000 9374 3516Department of Geriatric Medicine, Austin Health, Heidelberg, VIC 3084 Australia ,grid.1008.90000 0001 2179 088XDepartment of Medicine – Austin Health, University of Melbourne, Heidelberg, VIC 3084 Australia
| | - Craig Aboltins
- grid.410684.f0000 0004 0456 4276Department of Infectious Diseases, Northern Health, Epping, Vic 3076 Australia ,grid.1008.90000 0001 2179 088XDepartment of Medicine, Northern Clinical School, University of Melbourne, Epping VIC 3076, Australia
| | - Douglas Johnson
- grid.1008.90000 0001 2179 088XDepartment of Medicine – Royal Melbourne Hospital, University of Melbourne, Parkville, VIC 3010 Australia ,grid.416153.40000 0004 0624 1200Departments of General Medicine and Infectious Diseases, Royal Melbourne Hospital, Parkville VIC 3050, Australia
| | - Jason Kwong
- grid.1008.90000 0001 2179 088XDepartment of Medicine – Austin Health, University of Melbourne, Heidelberg, VIC 3084 Australia ,grid.410678.c0000 0000 9374 3516Department of Infectious Diseases, Austin Health, Heidelberg VIC 3084, Australia ,grid.1008.90000 0001 2179 088XDepartment of Microbiology & Immunology, University of Melbourne at the Peter Doherty Institute for Infection & Immunity, Melbourne VIC 3000, Australia
| | - Karrie Long
- grid.416153.40000 0004 0624 1200Director Nursing Research Hub, Royal Melbourne Hospital, Parkville VIC 3050, Australia
| | - Judy McCahon
- Consumer Representative of the IMMERSE Research Team, and Melbourne Academic Centre for Health, Parkville VIC 3050, Australia
| | - Wen K. Lim
- grid.416153.40000 0004 0624 1200Department of Aged Care, Royal Melbourne Hospital, Level 8 CRM, 300 Grattan Street, Parkville, VIC 3050 Australia ,grid.1008.90000 0001 2179 088XDepartment of Medicine – Royal Melbourne Hospital, University of Melbourne, Parkville, VIC 3010 Australia
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Bridey C, Le Dref G, Bocquier A, Bonnay S, Pulcini C, Thilly N. Nurses' perceptions of the potential evolution of their role in antibiotic stewardship in nursing homes: a French qualitative study. JAC Antimicrob Resist 2023; 5:dlad008. [PMID: 36743529 PMCID: PMC9891345 DOI: 10.1093/jacamr/dlad008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 01/10/2023] [Indexed: 02/04/2023] Open
Abstract
Background In nursing homes, infections and antibiotic prescriptions are frequent. Nursing home nurses (NHNs) and advanced practice registered nurses (APRNs) could promote antibiotic stewardship (ABS). Few studies have explored nurses' knowledge, perceptions and practices towards ABS in nursing homes and none has investigated the potential evolution of their roles. Objectives To explore French nurses' perceptions on ABS, current and future potential roles in ABS in nursing homes, as well as facilitators and barriers. Methods We conducted a qualitative study in north-eastern France between October 2020 and March 2021 using semi-structured individual interviews with NHNs and a focus group with APRNs. Transcripts of the interviews were analysed using a thematic analysis. Results Twenty NHNs and seven APRNs participated. They were aware of antibiotic misuse and potential adverse events but lacked knowledge on some ABS aspects. NHNs' current ABS roles ranged from the detection of clinical infectious signs to clinical monitoring of residents, with some heterogeneity between nurses. They had positive opinions towards playing a more prominent role in ABS. In the future, with additional training, changes in the legislative framework and greater multidisciplinary teamwork, NHNs thought they could prescribe laboratory microbiological analyses and some targeted antibiotic treatments. APRNs thought they could prescribe first-line antibiotics for urinary tract infections. Conclusions French NHNs' current ABS roles could be expanded and new roles might be considered while taking into account several facilitators and barriers. According to APRNs, they could help to compensate for the limited presence of doctors in nursing homes and develop infectious diseases skills.
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Affiliation(s)
| | | | | | | | - Céline Pulcini
- Université de Lorraine, APEMAC, F-54000 Nancy, France,Université de Lorraine, CHRU-Nancy, Service des Maladies Infectieuses et Tropicales, F-54000 Nancy, France
| | - Nathalie Thilly
- Université de Lorraine, APEMAC, F-54000 Nancy, France,Université de Lorraine, CHRU-Nancy, Département Méthodologie, Promotion, Investigation, F-54000 Nancy, France
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Gillani SW, Shahwan MKS, Szollosi DE. A questionnaire based survey among pharmacy practitioners to evaluate the level of knowledge and confidence towards antimicrobial stewardship. Pharm Pract (Granada) 2023; 21:2757. [PMID: 37090455 PMCID: PMC10117304 DOI: 10.18549/pharmpract.2023.1.2757] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 11/02/2022] [Indexed: 04/08/2023] Open
Abstract
Objective Our study aimed to assess the knowledge, understanding and confidence of the practicing pharmacists in UAE as an antimicrobial Stewards. Antimicrobial resistance threatens the achievements of modern medicine globally, and it's highly required for the AMS principles to be implemented in our communities. Methods A cross-sectional online- questionnaire based survey was used among UAE pharmacy practitioners from different areas of practice who are holding pharmaceutical degrees and/or licensed pharmacists. The questionnaire was sent to the participants via social media platforms. The questionnaire was validated, and reliability assessment was made prior to the conduct. Results A total of 117 pharmacists responded to this study, out of which (70.9%, n=83) were females. Pharmacists which are from various practice fields participated in the survey, but the majority were pharmacists in Hospital pharmacies or Clinical pharmacists (47%, n=55), also community pharmacists (35.9%, n=42), while only (16.9%, n=20) ware from other areas of pharmacy including industrial pharmacy and academia. The majority of participants 88.9% (n= 104) were interested in pursuing their career as an Infectious disease pharmacist or getting a certificate in antimicrobial stewardship. The mean scores in the knowledge towards antimicrobial resistance was 3.75 (poor: 1-1.6, moderate: 1.7-3.3. Good 3.4-5), indicates that the pharmacists have a good level of knowledge towards AMR. A total of 84.3% of participants succeeded in Identifying the correct intervention for antibiotic resistance. The findings also showed that the total mean score of hospital pharmacists (mean=10.6±1.12), and the average of the scores of community pharmacists (mean=9.8±1.38), were non-significant between the different area of practice. 52.3% of the participants had a training on antimicrobial stewardship during their experiential rotation which reflected on their confidence in their performance and knowledge assessment (p value < 0.05). Conclusion The study concluded good knowledge and high confidence levels among practicing pharmacists in UAE. However, the findings also identify areas of improvement in the practicing pharmacist, and the significant relationship between the knowledge and confidence scores reflects the ability of the practicing pharmacists to integrate the AMS principles within the UAE, which aligns with the attainability of the improvement.
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Affiliation(s)
- Syed Wasif Gillani
- Associate Professor, Department of Pharmacy Practice, College of Pharmacy, Gulf Medical University.
| | | | - Doreen E Szollosi
- Assistant Dean of Academic Affairs, Associate Professor of Pharmaceutical Sciences, University of Saint Joseph, School of Pharmacy & Physician Assistant Studies, Lourdes 106, 1678 Asylum Avenue, West Hartford, CT 06117.
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Di KN, Tay ST, Sri La Sri Ponnampalavanar S, Pham DT, Wong LP. Physician's Perspectives on Factors Influencing Antibiotic Resistance: A Qualitative Study in Vietnam. Healthcare (Basel) 2022; 11:healthcare11010126. [PMID: 36611587 PMCID: PMC9819556 DOI: 10.3390/healthcare11010126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 12/19/2022] [Accepted: 12/26/2022] [Indexed: 01/03/2023] Open
Abstract
(1) Background: The antibiotic resistance (ABR) rates are escalating to seriously high levels worldwide. This study was conducted to determine physicians' perspectives on factors influencing ABR in Vietnam. (2) Methods: Focus group discussion (FGD) was conducted through in-depth interviews on ABR perspectives with 5-6 physicians from different geographical locations and hospitals in Vietnam between March and June 2020. The research questions were focused on three main themes of (a) knowledge deficiency on ABR and hospital-acquired infection, (b) antibiotic prescribing practice among clinicians in the healthcare setting, and (c) regulations and hospital policies on antibiotic use. The descriptive analysis was performed using QRS NVivo software. (3) Results: A total of six FGDs were conducted among 34 physicians (18 males, 16 females) aged 26-53 years old from six public and six private hospitals in Vietnam. Most of the participants were attending physicians (85.3%) and had 5-10 years of experience in surgical wards (55.9%). For theme (a), a majority of participants agreed that they had adequate information updates on how ABR develops in their clinical setting; and were well aware of hospital-acquired infections. For theme (b), the participants agreed that WHO guidelines and Vietnam national guidelines were two important reference documents in guiding physicians in antibiotic use. For theme (c), the FGD study revealed awareness of ABR, hospital antibiotic policies, and procedures for administrators on antibiotic use that were updated and complied with. (4) Conclusions: While different levels of control measures against ABR are ongoing in Vietnam, several weaknesses in the current antibiotic prescribing strategies in the hospital and clinical setting management policies have been identified in the healthcare system. The research findings will be helpful for policymakers to have better plans of action against ABR in Vietnam.
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Affiliation(s)
- Khanh Nguyen Di
- Department of Academic Affairs—Testing, Dong Nai Technology University, Nguyen Khuyen Street, Trang Dai Ward, Bien Hoa City 810000, Dong Nai, Vietnam
- Department of Social and Preventive Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur 50603, Malaysia
- Correspondence: (K.N.D.); (L.P.W.)
| | - Sun Tee Tay
- Department of Medical Microbiology, Faculty of Medicine, Universiti Malaya, Kuala Lumpur 50603, Malaysia
| | | | - Duy Toan Pham
- Department of Chemistry, College of Natural Sciences, Can Tho University, Can Tho 900000, Vietnam
| | - Li Ping Wong
- Department of Social and Preventive Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur 50603, Malaysia
- Correspondence: (K.N.D.); (L.P.W.)
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Gillani SW, Shahwan MKS, Szollosi DE. A questionnaire based survey among pharmacy practitioners to evaluate the level of knowledge and confidence towards antimicrobial stewardship. Pharm Pract (Granada) 2022; 20:2757. [PMID: 36793910 PMCID: PMC9891779 DOI: 10.18549/pharmpract.2022.4.2757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 11/02/2022] [Indexed: 12/13/2022] Open
Abstract
Objective Our study aimed to assess the knowledge, understanding and confidence of the practicing pharmacists in UAE as an antimicrobial Stewards. Antimicrobial resistance threatens the achievements of modern medicine globally, and it's highly required for the AMS principles to be implemented in our communities. Methods A cross-sectional online- questionnaire based survey was used among UAE pharmacy practitioners from different areas of practice who are holding pharmaceutical degrees and/or licensed pharmacists. The questionnaire was sent to the participants via social media platforms. The questionnaire was validated, and reliability assessment was made prior to the conduct. Results A total of 117 pharmacists responded to this study, out of which (70.9%, n=83) were females. Pharmacists which are from various practice fields participated in the survey, but the majority were pharmacists in Hospital pharmacies or Clinical pharmacists (47%, n=55), also community pharmacists (35.9%, n=42), while only (16.9%, n=20) ware from other areas of pharmacy including industrial pharmacy and academia. The majority of participants 88.9% (n= 104) were interested in pursuing their career as an Infectious disease pharmacist or getting a certificate in antimicrobial stewardship. The mean scores in the knowledge towards antimicrobial resistance was 3.75 (poor: 1-1.6, moderate: 1.7-3.3, Good: 3.4-5), indicates that the pharmacists have a good level of knowledge towards AMR. A total of 84.3% of participants succeeded in Identifying the correct intervention for antibiotic resistance. The findings also showed that the total mean score of hospital pharmacists (mean=10.6±1.12), and the average of the scores of community pharmacists (mean=9.8±1.38), were non-significant between the different area of practice. 52.3% of the participants had a training on antimicrobial stewardship during their experiential rotation which reflected on their confidence in their performance and knowledge assessment (p value < 0.05). Conclusion The study concluded good knowledge and high confidence levels among practicing pharmacists in UAE. However, the findings also identify areas of improvement in the practicing pharmacist, and the significant relationship between the knowledge and confidence scores reflects the ability of the practicing pharmacists to integrate the AMS principles within the UAE, which aligns with the attainability of the improvement.
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Affiliation(s)
- Syed Wasif Gillani
- Associate Professor, Department of Pharmacy Practice, College of Pharmacy, Gulf Medical University.
| | | | - Doreen E Szollosi
- Assistant Dean of Academic Affairs, Associate Professor of Pharmaceutical Sciences, University of Saint Joseph, School of Pharmacy & Physician Assistant Studies, Lourdes 106, 1678 Asylum Avenue, West Hartford, CT 06117.
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11
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Hall J, Hawkins O, Montgomery A, Singh S, Mullan J, Degeling C. Dismantling antibiotic infrastructures in residential aged care: The invisible work of antimicrobial stewardship (AMS). Soc Sci Med 2022; 305:115094. [PMID: 35690033 DOI: 10.1016/j.socscimed.2022.115094] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 05/25/2022] [Accepted: 05/27/2022] [Indexed: 10/18/2022]
Abstract
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.
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Affiliation(s)
- Julie Hall
- Australian Centre for Health Engagement, Evidence and Values, The Faculty of Arts, Social Sciences and Humanities, University of Wollongong, NSW, Australia
| | - Olivia Hawkins
- Australian Centre for Health Engagement, Evidence and Values, The Faculty of Arts, Social Sciences and Humanities, University of Wollongong, NSW, Australia
| | - Amy Montgomery
- School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, NSW, Australia
| | - Saniya Singh
- Australian Centre for Health Engagement, Evidence and Values, The Faculty of Arts, Social Sciences and Humanities, University of Wollongong, NSW, Australia; School of Psychology, University of Wollongong, NSW, Australia
| | - Judy Mullan
- School of Medicine, Faculty of Science, Medicine and Health, University of Wollongong, NSW, Australia; Centre for Health Research Illawarra Shoalhaven Population, Faculty of Science, Medicine and Health, University of Wollongong, NSW, Australia
| | - Chris Degeling
- Australian Centre for Health Engagement, Evidence and Values, The Faculty of Arts, Social Sciences and Humanities, University of Wollongong, NSW, Australia.
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12
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McArthur C, Bai Y, Hewston P, Giangregorio L, Straus S, Papaioannou A. Barriers and facilitators to implementing evidence-based guidelines in long-term care: a qualitative evidence synthesis. Implement Sci 2021; 16:70. [PMID: 34243789 PMCID: PMC8267230 DOI: 10.1186/s13012-021-01140-0] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 06/24/2021] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The long-term care setting poses unique challenges and opportunities for effective knowledge translation. The objectives of this review are to (1) synthesize barriers and facilitators to implementing evidence-based guidelines in long-term care, as defined as a home where residents require 24-h nursing care, and 50% of the population is over the age of 65 years; and (2) map barriers and facilitators to the Behaviour Change Wheel framework to inform theory-guided knowledge translation strategies. METHODS Following the guidance of the Cochrane Qualitative and Implementation Methods Group Guidance Series and the ENTREQ reporting guidelines, we systematically reviewed the reported experiences of long-term care staff on implementing evidence-based guidelines into practice. MEDLINE Pubmed, EMBASE Ovid, and CINAHL were searched from the earliest date available until May 2021. Two independent reviewers selected primary studies for inclusion if they were conducted in long-term care and reported the perspective or experiences of long-term care staff with implementing an evidence-based practice guideline about health conditions. Appraisal of the included studies was conducted using the Critical Appraisal Skills Programme Checklist and confidence in the findings with the GRADE-CERQual approach. FINDINGS After screening 2680 abstracts, we retrieved 115 full-text articles; 33 of these articles met the inclusion criteria. Barriers included time constraints and inadequate staffing, cost and lack of resources, and lack of teamwork and organizational support. Facilitators included leadership and champions, well-designed strategies, protocols, and resources, and adequate services, resources, and time. The most frequent Behaviour Change Wheel components were physical and social opportunity and psychological capability. We concluded moderate or high confidence in all but one of our review findings. CONCLUSIONS Future knowledge translation strategies to implement guidelines in long-term care should target physical and social opportunity and psychological capability, and include interventions such as environmental restructuring, training, and education.
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Affiliation(s)
- Caitlin McArthur
- Dalhousie University, 5869 University Avenue, Halifax, Nova Scotia, B3H 4R2, Canada. .,GERAS Centre for Aging Research, 88 Maplewood Avenue, Hamilton, Ontario, L8M 1W9, Canada.
| | - Yuxin Bai
- GERAS Centre for Aging Research, 88 Maplewood Avenue, Hamilton, Ontario, L8M 1W9, Canada.,Master University, 1280 Main Street West, Hamilton, Ontario, L8S 4L8, Canada
| | - Patricia Hewston
- GERAS Centre for Aging Research, 88 Maplewood Avenue, Hamilton, Ontario, L8M 1W9, Canada.,Master University, 1280 Main Street West, Hamilton, Ontario, L8S 4L8, Canada
| | - Lora Giangregorio
- University of Waterloo, 200 University Avenue West, Waterloo, Ontario, N2L 3G1, Canada.,Schlegel-UW Research Institute for Aging, 150 Laurelwood Drive, Waterloo, Ontario, N2J 0E2, Canada
| | - Sharon Straus
- University of Toronto, 27 King's College Circle, Toronto, Ontario, M5S 1A4, Canada
| | - Alexandra Papaioannou
- GERAS Centre for Aging Research, 88 Maplewood Avenue, Hamilton, Ontario, L8M 1W9, Canada.,Master University, 1280 Main Street West, Hamilton, Ontario, L8S 4L8, Canada
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13
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Sayegh N, Hallit S, Hallit R, Saleh N, Zeidan RK. Physicians' attitudes on the implementation of an antimicrobial stewardship program in Lebanese hospitals. Pharm Pract (Granada) 2021; 19:2192. [PMID: 33727992 PMCID: PMC7939116 DOI: 10.18549/pharmpract.2021.1.2192] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 02/14/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Misuse of antibiotics and antimicrobial resistance are global concerns. Antibiotic stewardship programs (ASP) are advocated to reduce pathogens resistance by ensuring appropriate antimicrobial use. Several factors affect the implementation of ASPs in hospitals. The size and types of care provided, as well as the complexity of antibiotic prescription, are all issues that are considered in designing an effective hospital-based program. OBJECTIVES To examine physicians' attitude on implementation of an antimicrobial stewardship program in Lebanese hospitals. METHODS A descriptive cross-sectional survey was carried out using an online questionnaire. Survey items assessed ASP implementations, physicians' attitudes, usefulness of the tools, and barriers of implementation. The questionnaire was based on the Center for Disease Control core-elements. RESULTS 158 physicians completed the survey with a response rate of 4%. Our results showed that the majority (66%) of physicians were familiar with the ASP concept. Most respondents reported a lack of regular educational programs (41%), as well as a lack of support from the medical staff (76%). This study demonstrated positive attitudes and support for ASP implementation. However, ASPs were reported as affecting physicians' autonomy by 34 % of the participants. Antibiotic rounds and prospective audit and feedback were rated as most useful interaction methods with the ASPs. A minimal support of the Ministry Of Public Health, as well as the absence of regulation and of national guidelines, were reported as barriers to ASPs. The shortage of Infectious Disease physicians was seen as a barrier by half of the respondents. CONCLUSIONS Physicians are supportive of ASP, with preference for interventions that provide information and education rather than restrictive ones. Additional research is needed on a larger sample of physicians.
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Affiliation(s)
- Nathalie Sayegh
- Faculty of Public Health, Lebanese University. Fanar (Lebanon).
| | - Souheil Hallit
- Faculty of Medicine and Medical Sciences, Holy Spirit University of Kaslik (USEK). Jounieh (Lebanon).
| | - Rabih Hallit
- Faculty of Medicine and Medical Sciences, Holy Spirit University of Kaslik (USEK). Jounieh (Lebanon).
| | - Nadine Saleh
- Faculty of Public Health, Lebanese University. Fanar (Lebanon).
| | - Rouba K Zeidan
- Faculty of Public Health, Lebanese University. Fanar (Lebanon).
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14
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Adre C, Jump RLP, Spires SS. Recommendations for Improving Antimicrobial Stewardship in Long-Term Care Settings Through Collaboration. Infect Dis Clin North Am 2020; 34:129-143. [PMID: 32008695 DOI: 10.1016/j.idc.2019.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Antimicrobial stewardship is a collaborative venture and antimicrobial stewardship in long-term care (LTC) settings is no exception. There are many barriers to implementing effective antimicrobial stewardship programs in LTC settings, including constrained financial resources, limited access to physicians and pharmacists with antimicrobial stewardship training, minimal on-site infectious syndrome diagnostics and laboratory expertise, and high rates of staff turnover. This article suggests that collaboration at the level of health care facilities and systems, with public health departments, with laboratory partners, and among personnel, including nursing staff, prescribers, and pharmacists, can lead to effective antimicrobial stewardship programs in LTC settings.
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Affiliation(s)
- Cullen Adre
- Tennessee Department of Health, Andrew Johnson Tower, 3.417C, 710 James Robertson Parkway, Nashville, TN 37243, USA.
| | - Robin L P Jump
- Geriatric Research Education and Clinical Center (GRECC); Specialty Care Center of Innovation at the VA Northeast Ohio Healthcare System, Cleveland, OH, USA; Division of Infectious Diseases and HIV Medicine, Department of Medicine, Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland, OH 44106, USA; Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland, OH 44106, USA
| | - Steven Schaeffer Spires
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Division of Infectious Diseases, Duke University School of Medicine, DUMC PO Box 102359, Durham, NC 27710, USA
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15
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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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16
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Gotterson F, Buising K, Manias E. Nurse role and contribution to antimicrobial stewardship: An integrative review. Int J Nurs Stud 2020; 117:103787. [PMID: 33647845 DOI: 10.1016/j.ijnurstu.2020.103787] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 08/05/2020] [Accepted: 09/28/2020] [Indexed: 01/22/2023]
Abstract
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.
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Affiliation(s)
- Fiona Gotterson
- National Centre for Antimicrobial Stewardship, The Peter Doherty Institute for Infections and Immunity, 792 Elizabeth St, Melbourne, VIC 3000, Australia; Department of Medicine, Building 181, University of Melbourne, Grattan St, Melbourne, VIC 3010, Australia.
| | - Kirsty Buising
- National Centre for Antimicrobial Stewardship, The Peter Doherty Institute for Infections and Immunity, 792 Elizabeth St, Melbourne, VIC 3000, Australia; Department of Medicine, Building 181, University of Melbourne, Grattan St, Melbourne, VIC 3010, Australia; Victorian Infectious Diseases Service, The Peter Doherty Institute for Infections and Immunity, 792 Elizabeth St, Melbourne, VIC 3000, Australia
| | - Elizabeth Manias
- Deakin University, School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Institute for Health Transformation, 221 Burwood Highway, Burwood, VIC 3125, Australia; The Royal Melbourne Hospital, Department of Medicine, Royal Parade, Parkville, VIC 3052, Australia
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17
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18
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Effect of antibiotic time-outs on modification of antibiotic prescriptions in nursing homes. Infect Control Hosp Epidemiol 2020; 41:635-640. [PMID: 32252841 PMCID: PMC9875214 DOI: 10.1017/ice.2020.75] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Antibiotic overuse and misuse is a common problem in nursing homes. Antibiotic time-out (ATO) interventions have led to improvements in antibiotic uses in hospitals, but their impact in nursing homes remain understudied. OBJECTIVE To evaluate the impact of a stewardship intervention, promoting use of ATOs on the frequency and types of antibiotic change events (ACEs) in nursing homes. DESIGN Controlled before-and-after intervention study. SETTING Nursing homes in Wisconsin and Pennsylvania. METHOD Data on antibiotic prescriptions in 11 nursing homes were collected for 25 months. We categorized ACEs as (1) early discontinuation, (2) class modification, or (3) administration modification. Class modification ACEs were further classified based on whether the change narrowed, expanded, or had no effect on bacterial spectrum coverage. Analyses were performed using a difference-in-difference (DiD) approach. RESULT Of 2,647 antibiotic events initiated in study nursing homes, 376 (14.2%) were associated with an ACE. The overall proportion of ACEs did not significantly differ between intervention and control nursing homes. Early discontinuation ACEs increased in intervention nursing homes (DiD, 2.5%; P = .01), primarily affecting residents initiated on broad-spectrum antibiotics (DiD, 2.9%; P < .01). Class modification ACEs decreased in intervention nursing homes but remained unchanged in control nursing homes. CONCLUSION The impact of an ATO intervention in study nursing homes was mixed with increases in early discontinuation ACEs offset by reductions in class modification ACEs. More research on the potential value of ATO interventions in nursing homes is warranted.
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19
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Tark A, Estrada LV, Tresgallo ME, Quigley DD, Stone PW, Agarwal M. Palliative care and infection management at end of life in nursing homes: A descriptive survey. Palliat Med 2020; 34:580-588. [PMID: 32153248 PMCID: PMC7405898 DOI: 10.1177/0269216320902672] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Infections are common occurrences at end of life that are associated with high rates of morbidity and mortality among frail elderly individuals. The problem of infections in nursing homes has led to a subsequent overuse and misuse of antibiotics in this already-frail population. Improving palliative care in nursing homes has been proposed as a key strategy to reduce the use of antibiotics. AIM The aim of this study was to describe the current status of how nursing homes integrates palliative care and infection management at end of life across the nation. DESIGN This is a cross-sectional survey of nationally representative US nursing homes. SETTING/PARTICIPANTS Between November 2017 and October 2018, a survey was conducted with a nationally representative random sample of nursing homes and 892 surveys were completed (49% response rate). The weighted study sample represented 15,381 nursing homes across the nation. RESULTS Most nursing homes engaged in care plan documentation on what is important to residents (90.43%) and discussed spiritual needs of terminally ill residents (89.50%). In the event of aspiration pneumonia in terminally ill residents, 59.43% of nursing homes responded that resident would be transferred to the hospital. In suspected urinary tract infection among terminally ill residents, 66.62% of nursing homes responded that the resident will be treated with antibiotics. CONCLUSION The study found wide variations in nursing home palliative care practices, particularly for timing of end-of-life care discussions, and suboptimal care reported for antibiotic usage. Further education for nursing home staff on appropriate antibiotic usage and best practices to integrate infection management in palliative care at the end of life is needed.
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Affiliation(s)
- Aluem Tark
- School of Nursing, Columbia University, New York, NY, USA
| | - Leah V Estrada
- School of Nursing, Columbia University, New York, NY, USA
| | | | | | | | - Mansi Agarwal
- School of Nursing, Columbia University, New York, NY, USA
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20
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Fu CJ, Mantell E, Stone PW, Agarwal M. Characteristics of nursing homes with comprehensive antibiotic stewardship programs: Results of a national survey. Am J Infect Control 2020; 48:13-18. [PMID: 31447117 PMCID: PMC6935405 DOI: 10.1016/j.ajic.2019.07.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 07/17/2019] [Accepted: 07/18/2019] [Indexed: 01/20/2023]
Abstract
BACKGROUND Antibiotic stewardship in nursing homes (NHs) is a high priority owing to intense antibiotic use and increased risk of adverse events. Updated Centers for Medicare and Medicaid Services regulations required NHs to establish antibiotic stewardship programs (ASPs). This study describes the current state of NH ASPs. METHODS A nationally representative survey of NHs was conducted in 2018. ASP comprehensiveness, infection preventionist (IP) training, participation in Quality Innovation Network-Quality Improvement Organization (QIN-QIO) activities, and facility and staff characteristics were analyzed using weighted descriptive statistics and multinomial regression models. RESULTS Of 861 NHs, 33.2% (6-7) had "comprehensive" ASP policies, 41.1% (4-5) had "moderately comprehensive" ASP policies, and 25.6% (≤ 3) had "not comprehensive" ASP policies. Data collection on antibiotic use was most reported (91.4%), and restricting use of specific antibiotics was least reported (19.0%). Comprehensive ASPs were associated with QIN-QIO involvement; moderate and comprehensive ASPs were associated with IP training and high occupancy. DISCUSSION Immediately following Centers for Medicare and Medicaid Services regulation changes, a majority of NHs had moderately comprehensive or comprehensive ASPs. Rates for each policy and infection control-trained IPs increased from previous studies. CONCLUSIONS NH ASPs are becoming more comprehensive. Infection control training and partnerships with QIN-QIOs can support NHs to increase ASP comprehensiveness.
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Affiliation(s)
| | | | | | - Mansi Agarwal
- Columbia University School of Nursing, New York, NY.
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21
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Dowson L, Rajkhowa A, Buising K, Kong DC, Stuart RL, Thursky K, Bennett N. The 2018 Aged Care National Antimicrobial Prescribing Survey: results show room for improvement. Aust Prescr 2019; 42:200-203. [PMID: 31937990 PMCID: PMC6954873 DOI: 10.18773/austprescr.2019.066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
The annual Aged Care National Antimicrobial Prescribing Survey aims to identify local and national prescribing issues and guide antimicrobial stewardship goals
In the 2018 point prevalence survey, medication charts of over 20,000 residents were reviewed from 407 participating facilities across Australia
On the day of the survey, almost 10% of residents were prescribed an antimicrobial
Nearly two-thirds of recently prescribed antimicrobials were for residents who had no documented signs or symptoms of infection
Over a quarter of antimicrobials had been prescribed for longer than six months
Incomplete documentation was a prominent barrier to proper review of antimicrobial therapy, with the indication, review date or stop date not documented for many prescriptions
Recommendations include using appropriate microbiological testing to guide prescribing, following national antimicrobial prescribing guidelines, documenting the indication for the antimicrobial, and its start, stop and review dates, and monitoring and re-evaluating long-term antimicrobial use
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Affiliation(s)
- Leslie Dowson
- Monash University, Melbourne, Vic.,National Centre for Antimicrobial Stewardship, Melbourne, Vic
| | - Arjun Rajkhowa
- National Centre for Antimicrobial Stewardship, Melbourne, Vic.,University of Melbourne, Vic
| | - Kirsty Buising
- National Centre for Antimicrobial Stewardship, Melbourne, Vic.,University of Melbourne, Vic.,Victorian Infectious Diseases Service, Melbourne, Vic
| | - David Cm Kong
- Monash University, Melbourne, Vic.,National Centre for Antimicrobial Stewardship, Melbourne, Vic.,Ballarat Health Services, Ballarat, Vic
| | - Rhonda L Stuart
- Monash University, Melbourne, Vic.,National Centre for Antimicrobial Stewardship, Melbourne, Vic.,Monash Health, Clayton, Vic
| | - Karin Thursky
- National Centre for Antimicrobial Stewardship, Melbourne, Vic.,University of Melbourne, Vic.,Peter MacCallum Cancer Centre, Melbourne, Vic
| | - Noleen Bennett
- National Centre for Antimicrobial Stewardship, Melbourne, Vic.,University of Melbourne, Vic.,Victorian Healthcare Associated Infection Surveillance System Coordinating Centre, Melbourne, Vic
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22
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Rose J, Crosbie M, Stewart A. A qualitative literature review exploring the drivers influencing antibiotic over-prescribing by GPs in primary care and recommendations to reduce unnecessary prescribing. Perspect Public Health 2019; 141:19-27. [PMID: 31633458 DOI: 10.1177/1757913919879183] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIMS This qualitative literature review aims to critically assess and analyse published literature to determine drivers influencing over-prescribing by general practitioners (GPs) in primary care, exploring their views and opinions, and also to determine how antibiotic prescribing can be improved and unnecessary prescribing reduced, thus reducing the threat to public health from antibiotic resistance. It is intended to develop new thinking in this area and add to existing knowledge concerning GPs' antibiotic prescribing behaviour. METHODS Thematic analysis following Braun and Clarke's 2006 framework was used to analyse 17 qualitative studies chosen from EBSCOhost databases, focusing on GPs' views of antibiotic prescribing in primary care, with specific search strategies and inclusion criteria to ensure study quality and trustworthiness. RESULTS Three main themes and nine sub-themes were generated from the studies. The first main theme discussed GP factors related to over-prescribing, the main drivers being GP attitudes and feelings and anxiety/fear concerning prescribing. The second theme highlighted external factors, with pressures from time and financial issues as the main drivers within this theme. The final theme marked patient pressure, demand and expectation with lack of patient education as the major drivers affecting GP over-prescribing. CONCLUSION The findings of this research show GPs' antibiotic prescribing in primary care is complex, being influenced by many internal and external factors. A multifaceted approach to interventions targeting the drivers identified could significantly reduce the level of antibiotic prescribing thus minimising the impact of antibiotic resistance and promoting a more efficient working environment for GPs and patients alike.
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Affiliation(s)
- Joanna Rose
- University of Wolverhampton, Wulfruna Street, Wolverhampton WV1 1LY, UK
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Dowson L, Marshall C, Buising K, Friedman ND, Kong DCM, Stuart RL. Optimizing treatment of respiratory tract infections in nursing homes: Nurse-initiated polymerase chain reaction testing. Am J Infect Control 2019; 47:911-915. [PMID: 30851997 PMCID: PMC7172091 DOI: 10.1016/j.ajic.2019.02.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Revised: 02/03/2019] [Accepted: 02/04/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Diagnostic testing using polymerase chain reaction (PCR) is infrequently initiated for diagnosis of respiratory tract infections (RTIs) in nursing homes. The objectives of this study were to determine the feasibility of implementing nurse-initiated PCR testing of respiratory specimens in nursing home settings and to compare antibiotic prescribing prior to and during the implementation. METHODS This was a pragmatic, historically controlled study in 3 nursing homes (181 total beds) in Melbourne, Australia. RESULTS The number of PCR tests of respiratory specimens (over 12 months) increased from 5 to 67 when nurses could initiate the tests. Residents with RTI symptoms had a virus identified by PCR in 50.7% of tests, including 14 positive for influenza. Six outbreaks were identified. When clustering was taken into consideration, incidence rates of antibiotic days of therapy did not change (incidence rate ratio = 0.94, 95% confidence interval, 0.25-3.35, P = .92) despite identification of more viral pathogens. CONCLUSIONS In nursing homes, nurse-initiated PCR testing of respiratory specimens is feasible and useful in terms of identifying the cause of many RTIs and outbreaks, and viruses are common in this context. However, the current study suggests the availability of these test results alone does not impact antibiotic prescribing.
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Affiliation(s)
- Leslie Dowson
- National Centre for Antimicrobial Stewardship, Peter Doherty Institute for Infections and Immunity, Melbourne, Victoria, Australia; Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Caroline Marshall
- National Centre for Antimicrobial Stewardship, Peter Doherty Institute for Infections and Immunity, Melbourne, Victoria, Australia; Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia; Victorian Infectious Diseases Service, Peter Doherty Institute for Infections and Immunity, Melbourne, Victoria, Australia; Infection Prevention and Surveillance Service, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Kirsty Buising
- National Centre for Antimicrobial Stewardship, Peter Doherty Institute for Infections and Immunity, Melbourne, Victoria, Australia; Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia; Victorian Infectious Diseases Service, Peter Doherty Institute for Infections and Immunity, Melbourne, Victoria, Australia
| | - N Deborah Friedman
- National Centre for Antimicrobial Stewardship, Peter Doherty Institute for Infections and Immunity, Melbourne, Victoria, Australia; School of Medicine, Deakin University, Geelong, Victoria, Australia; Departments of General Medicine and Infectious Diseases, Barwon Health, Geelong, Victoria, Australia
| | - David C M Kong
- National Centre for Antimicrobial Stewardship, Peter Doherty Institute for Infections and Immunity, Melbourne, Victoria, Australia; Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia; Pharmacy Department, Ballarat Health Services, Ballarat, Victoria, Australia
| | - Rhonda L Stuart
- National Centre for Antimicrobial Stewardship, Peter Doherty Institute for Infections and Immunity, Melbourne, Victoria, Australia; Department of Medicine, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia; Monash Infectious Diseases and Infection Control and Epidemiology, Monash Health, Clayton, Victoria, Australia.
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Stone PW, Herzig CTA, Agarwal M, Pogorzelska-Maziarz M, Dick AW. Nursing Home Infection Control Program Characteristics, CMS Citations, and Implementation of Antibiotic Stewardship Policies: A National Study. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2018; 55:46958018778636. [PMID: 29806527 PMCID: PMC5974557 DOI: 10.1177/0046958018778636] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Recently, the Centers for Medicare & Medicaid Services (CMS) final rule required that nursing homes (NHs) develop an infection control program that includes an antibiotic stewardship component and employs a trained infection preventionist (IP). The objectives of this study were to provide a baseline assessment of (1) NH facility and infection control program characteristics associated with having an infection control deficiency citation and (2) associations between IP training and the presence of antibiotic stewardship policies, controlling for NH characteristics. A cross-sectional survey of 2514 randomly sampled US NHs was conducted to assess IP training, staff turnover, and infection control program characteristics (ie, frequency of infection control committee meetings and the presence of 7 antibiotic stewardship policies). Responses were linked to concurrent Certification and Survey Provider Enhanced Reporting data, which contain information about NH facility characteristics and citations. Descriptive statistics and multivariable regression analyses were conducted to account for NH characteristics. Surveys were received from 990 NHs; 922 had complete data. One-third of NHs in this sample received an infection control deficiency citation. The NHs that received deficiency citations were more likely to have committees that met weekly/monthly versus quarterly ( P < .01). The IPs in 39% of facilities had received specialized training. Less than 3% of trained IPs were certified in infection control. The NHs with trained IPs were more likely to have 5 of the 7 components of antibiotic stewardship in place (all P < .05). The IP training, although infrequent, was associated with the presence of antibiotic stewardship policies. Receiving an infection control citation was associated with more frequent infection control committee meetings. Training and support of IPs is needed to ensure infection control and antibiotic stewardship in NHs. As the CMS rule becomes implemented, more research is warranted. There is a need for increase in trained IPs in US NHs. These data can be used to evaluate the effectiveness of the CMS final rule on infection management processes in US NHs.
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Affiliation(s)
| | | | - Mansi Agarwal
- 1 Columbia University School of Nursing, New York, NY, USA
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Carter RR, Montpetite MM, Jump RLP. Mixed-Methods Pilot Study to Assess Perceptions of Antimicrobial Stewardship in Nursing Homes. J Am Geriatr Soc 2017; 65:1073-1078. [PMID: 28152171 PMCID: PMC5435504 DOI: 10.1111/jgs.14766] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To identify features of community nursing home (NH) environments associated with lower rates of overall antibiotic use. DESIGN This pilot study used an explanatory sequential design that incorporated comparative feedback about antibiotic use to inform a discussion about antimicrobial stewardship practices in community NHs. SETTING NHs. PARTICIPANTS Clinical leadership of five NHs. MEASUREMENTS For the quantitative phase, the number of antibiotic prescriptions, length of therapy, and days of therapy/1,000 days of care were measured at six NHs. For the qualitative phase, semistructured interviews were conducted with healthcare workers in leadership positions at five community NHs. Transcripts from the recorded interviews were assessed using emergent thematic analysis. For the triangulation phase, themes from the semistructured interviews were evaluated in the context of each NH's antibiotic use. RESULTS The number of antibiotic prescriptions ranged from 172 to 1,244, with 50% to 83% written for 7 days or fewer. All NHs reported a similar proportion of fluoroquinolone use (27-32% of days of therapy). Triangulation yielded six themes for which the environment at each facility ranged from less- to more-supportive antimicrobial stewardship: practice patterns, external influences, infection control, leadership, communication, and facility culture. All NHs reported pressure from well-intentioned family members to prescribe antibiotics. NHs with shorter lengths of therapy and lower overall antibiotic use were consonant with an environment more supportive of antimicrobial stewardship. CONCLUSION These findings suggest several features of NHs that are supportive of antimicrobial stewardship: practice patterns grounded in established diagnostic criteria, proactive infection control and prevention, open communication and interconnectedness among staff.
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Affiliation(s)
- Rebecca R Carter
- Department of Epidemiology and Biostatistics, School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Michelle M Montpetite
- Interprofessional Improvement Research, Education and Clinical Center, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio
| | - Robin L P Jump
- Geriatric Research Education and Clinical Center, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio.,Center of Innovation, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio.,Division of Infectious Diseases and HIV Medicine, Department of Medicine, Case Western Reserve University, Cleveland, Ohio
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26
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Pringle S, Simpson M, Nielsen S, Cooper C, Vanniasinkam T. Antibiotic prescribing practices in aged care facilities in regional NSW and the ACT. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2016. [DOI: 10.1002/jppr.1262] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Samantha Pringle
- School of Biomedical Sciences; Charles Sturt University; Wagga Wagga Australia
| | - Maree Simpson
- School of Biomedical Sciences; Charles Sturt University; Orange Australia
| | - Sharon Nielsen
- School of Biomedical Sciences; Charles Sturt University; Wagga Wagga Australia
| | - Carl Cooper
- School of Biomedical Sciences; Charles Sturt University; Wagga Wagga Australia
| | - Thiru Vanniasinkam
- School of Biomedical Sciences; Charles Sturt University; Wagga Wagga Australia
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27
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Eke-Usim AC, Rogers MAM, Gibson KE, Crnich C, Mody L. Constitutional Symptoms Trigger Diagnostic Testing Before Antibiotic Prescribing in High-Risk Nursing Home Residents. J Am Geriatr Soc 2016; 64:1975-1980. [PMID: 27655061 DOI: 10.1111/jgs.14286] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVES To evaluate the use of diagnostic testing before treating an infection in nursing home (NH) residents suspected of having a urinary tract infection (UTI) or pneumonia. DESIGN Prospective longitudinal study nested within a randomized trial, using data from control sites. SETTING Six NHs in southeast Michigan. PARTICIPANTS NH residents with an indwelling urinary catheter, enteral feeding tube, or both (N = 162) with 695 follow-up visits (189 (28%) visits with an infection). MEASUREMENTS Clinical and demographic data-including information on incident infections, antibiotic use, and results of diagnostic tests-were obtained at study enrollment, after 14 days, and monthly thereafter for up to 1 year. RESULTS One hundred (62%) NH residents had an incident infection requiring antibiotics, with substantial variations between NHs. In addition to presence of infection-specific symptoms, change in function was a significant predictor of ordering a chest X-ray to detect pneumonia (odds ratio (OR) = 1.7, P = .01). Similarly, change in mentation was a significant predictor of ordering a urinalysis (OR = 1.9, P = .02), chest X-ray (OR = 3.3, P < .001), and blood culture (OR = 2.3, P = .02). Antibiotics were used empirically, before laboratory results were available, in 50 of 233 suspected cases of UTI (21.5%) and 16 of 53 (30.2%) suspected cases of pneumonia. Antibiotics were used in 17% of visits without documented clinical or laboratory evidence of infection. CONCLUSION Constitutional symptoms such as change in function and mentation commonly lead to diagnostic testing and subsequent antibiotic prescribing. Antibiotic use often continues despite negative test results and should be a target for future interventions.
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Affiliation(s)
- Angela C Eke-Usim
- School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Mary A M Rogers
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Kristen E Gibson
- Division of Geriatric and Palliative Care Medicine, School of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Christopher Crnich
- School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Lona Mody
- Division of Geriatric and Palliative Care Medicine, School of Medicine, University of Michigan, Ann Arbor, Michigan. .,Geriatrics Research Education and Clinical Center, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan.
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Fleming A, Bradley C, Cullinan S, Byrne S. Antibiotic prescribing in long-term care facilities: a meta-synthesis of qualitative research. Drugs Aging 2016; 32:295-303. [PMID: 25832969 PMCID: PMC4412731 DOI: 10.1007/s40266-015-0252-2] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Objectives The objective of this review was to synthesize the findings of qualitative studies investigating the factors influencing antibiotic prescribing in long-term care facilities (LTCFs). These findings will inform the development of future antimicrobial stewardship strategies (AMS) in this setting. Methods We searched Embase, PubMed, PsycInfo, Social Science Citations Index and Google Scholar for all qualitative studies investigating health care professionals’ views on antibiotic prescribing in LTCFs. The quality of the papers was assessed using the Critical Appraisal Skills Programme (CASP) assessment tool for qualitative research. Thematic synthesis was used to integrate the emergent themes into an overall analytical theme. Results The synthesis of eight qualitative studies indicated that health care professionals and administrators have identified factors that influence antibiotic prescribing in LTCFs. These factors include variations in knowledge and practice among health care professionals, and the LTCF context, which is unique given the complex patient population and restricted access to doctors and diagnostic tests. The social factors underpinning the interaction between nurses, residents’ families and doctors also influence decision making around antibiotic prescribing. The study also found that there is an acknowledged need for collaborative, evidence-based AMS specific to LTCFs, as antibiotic prescribing is heavily influenced by factors unique to this setting. Conclusion This review highlighted the key contextual challenges for AMS in LTCFs. The findings provide an in-depth insight into the factors—such as the LTCF context, social factors, variability in knowledge and prescribing practices, and antimicrobial resistance—that impact on antibiotic prescribing and AMS strategies. These factors must be considered in order to ensure the feasibility and applicability of future AMS interventions. Electronic supplementary material The online version of this article (doi:10.1007/s40266-015-0252-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Aoife Fleming
- Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, Cork, Ireland,
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29
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Antimicrobial stewardship in long-term care facilities in Belgium: a questionnaire-based survey of nursing homes to evaluate initiatives and future developments. Antimicrob Resist Infect Control 2016; 5:7. [PMID: 26962446 PMCID: PMC4784372 DOI: 10.1186/s13756-016-0106-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 03/03/2016] [Indexed: 11/10/2022] Open
Abstract
Background The use of antimicrobials is intense and often inappropriate in long-term care facilities. Antimicrobial resistance has increased in acute and chronic care facilities, including those in Belgium. Evidence is lacking concerning antimicrobial stewardship programmes in chronic care settings. The medical coordinator practicing in Belgian nursing homes is a general practitioner designated to coordinate medical activity. He is likely to be the key position for effective implementation of such programmes. The aim of this study was to evaluate past, present, and future developments of antimicrobial stewardship programmes by surveying medical coordinators working in long-term care facilities in Belgium. Methods We conducted an online questionnaire-based survey of 327 Belgian medical coordinators. The questionnaire was composed of 33 questions divided into four sections: characteristics of the respondents, organisational frameworks for implementation of the antimicrobial stewardship programme, tools to promote appropriate antimicrobial use and priorities of action. Questions were multiple choice, rating scale, or free text. Results A total of 39 medical coordinators (12 %) completed the questionnaire. Past or present antimicrobial stewardship initiatives were reported by 23 % of respondents. The possibility of future developments was rated 2.7/5. The proposed key role of medical coordinators was rated <3/5 by 36 % of respondents. General practitioners, nursing staff, and hospital specialists are accepted as important roles. The use of antimicrobial guidelines was reported by only 19 % of respondents. Education was considered the cornerstone for any future developments. Specific diagnostic recommendations were considered useful, but chest x-rays were judged difficult to undertake. The top priority identified was to reduce unnecessary treatment of asymptomatic urinary infections. Conclusions Our study shows that the implementation of an antimicrobial stewardship programme is reported only in a minority of nursing homes. The possibility of future developments is uncertain. Nevertheless, the self-selected medical coordinators who responded to the survey reported a good knowledge of this complex problem. Despite a lack of optimism, medical coordinators seem to have the appropriate competencies to play a key role in antimicrobial stewardship in the future. Electronic supplementary material The online version of this article (doi:10.1186/s13756-016-0106-7) contains supplementary material, which is available to authorized users.
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Heath B, Bernhardt J, Michalski TJ, Crnich CJ, Moehring R, Schmader KE, Olds D, Higgins PA, Jump RL. Results of a Veterans Affairs employee education program on antimicrobial stewardship for older adults. Am J Infect Control 2016; 44:349-51. [PMID: 26553404 DOI: 10.1016/j.ajic.2015.09.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 09/19/2015] [Accepted: 09/21/2015] [Indexed: 10/22/2022]
Abstract
We describe a course in the Veterans Affairs (VA) Employee Education System designed to engage nursing staff working in VA long-term care facilities as partners in antimicrobial stewardship. We found that the course addressed an important knowledge gap. Our outcomes suggest opportunities to engage nursing staff in advancing antimicrobial stewardship, particularly in the long-term care setting.
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Antimicrobial Stewardship and Infection Prevention in Long-Term Care Settings: New Strategies to Prevent Resistant Organisms. CURRENT GERIATRICS REPORTS 2016. [DOI: 10.1007/s13670-016-0158-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Cairns KA, Roberts JA, Cotta MO, Cheng AC. Antimicrobial Stewardship in Australian Hospitals and Other Settings. Infect Dis Ther 2015; 4:27-38. [PMID: 26362294 PMCID: PMC4569646 DOI: 10.1007/s40121-015-0083-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Indexed: 11/25/2022] Open
Abstract
Australia’s model of antimicrobial stewardship (AMS) has evolved significantly over recent years, from a long-standing national approach of antimicrobial prescribing guidelines and antimicrobial prescribing restrictions to recent advances including the first National Antimicrobial Resistance Strategy and incorporating mandatory AMS as part of hospital accreditation standards. AMS programs are most commonly found in the hospital setting. Various models are used throughout the country based on the local context and resources available. Programs implemented at Alfred Health and the Royal Brisbane and Women’s Hospital represent two successful models in tertiary referral settings that accommodate a general ward setting as well as specialized areas with a high infection burden. Measurement of outcomes related to AMS activities remains poorly standardized, with process indicators such as antimicrobial utilization forming a large proportion of outcome measurement. Presently there is no requirement for any AMS outcome measurements to be reported externally. Point prevalence surveys of appropriateness of prescribing and compliance with prescribing guidelines are widely used at a national level. Despite this, there is still a paucity of published Australian data to support the effect of AMS on patient clinical outcomes. Private hospitals, the community, veterinary medicine and aged care sectors represent an important area for future AMS expansion within Australia. The AMS focus has traditionally been on prescribing restrictions (through the Commonwealth funding agencies); however, recent work has described other areas for improvement and development in both settings. AMS in Australia continues to evolve. The recent development of an Australian strategic plan to link antimicrobial utilization and resistance surveillance with policy represents an important step forward for the future of AMS in Australia.
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Affiliation(s)
- Kelly A Cairns
- Pharmacy Department, Alfred Health, Melbourne, VIC, Australia.
| | - Jason A Roberts
- Department of Intensive Care Medicine and Pharmacy Department, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia.,Burns Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, QLD, Australia.,School of Pharmacy, The University of Queensland, Brisbane, QLD, Australia
| | - Menino O Cotta
- Department of Intensive Care Medicine and Pharmacy Department, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia.,Burns Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, QLD, Australia.,School of Pharmacy, The University of Queensland, Brisbane, QLD, Australia.,Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - Allen C Cheng
- Infection Prevention and Healthcare Epidemiology Unit, Alfred Health, Melbourne, VIC, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
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Crnich CJ, Jump R, Trautner B, Sloane PD, Mody L. Optimizing Antibiotic Stewardship in Nursing Homes: A Narrative Review and Recommendations for Improvement. Drugs Aging 2015; 32:699-716. [PMID: 26316294 PMCID: PMC4579247 DOI: 10.1007/s40266-015-0292-7] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
The emerging crisis in antibiotic resistance and concern that we now sit on the precipice of a post-antibiotic era have given rise to advocacy at the highest levels for widespread adoption of programmes that promote judicious use of antibiotics. These antibiotic stewardship programmes, which seek to optimize antibiotic choice when clinically indicated and discourage antibiotic use when clinically unnecessary, are being implemented in an increasing number of acute care facilities, but their adoption has been slower in nursing homes. The antibiotic prescribing process in nursing homes is fundamentally different from that observed in hospital and clinic settings, with formidable challenges to implementation of effective antibiotic stewardship. Nevertheless, an emerging body of research points towards ways to improve antibiotic prescribing practices in nursing homes. This review summarizes the findings of this research and presents ways in which antibiotic stewardship can be implemented and optimized in the nursing home setting.
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Affiliation(s)
- Christopher J Crnich
- School of Medicine and Public Health, University of Wisconsin, 1685 Highland Avenue, MFCB 5217, Madison, WI, 53705, USA.
- William S. Middleton Veterans Affairs Hospital, Madison, WI, USA.
| | - Robin Jump
- Geriatric Research, Education and Clinical Center, Division of Internal Medicine, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, OH, USA
- Division of Infectious Disease, Department of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Barbara Trautner
- Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA
| | - Philip D Sloane
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Lona Mody
- Division of Geriatric and Palliative Care Medicine, University of Michigan, Ann Arbor, MI, USA
- Geriatric Research Education and Clinical Center, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
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Dyar OJ, Pagani L, Pulcini C. Strategies and challenges of antimicrobial stewardship in long-term care facilities. Clin Microbiol Infect 2014; 21:10-9. [PMID: 25636921 DOI: 10.1016/j.cmi.2014.09.005] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Revised: 09/17/2014] [Accepted: 09/24/2014] [Indexed: 11/30/2022]
Abstract
As people are living longer the demand for long-term care facilities (LTCFs) continues to rise. For many reasons, antimicrobials are used intensively in LTCFs, with up to a half of this use considered inappropriate or unnecessary. Over-use of antimicrobials can have direct adverse consequences for LTCF residents and promotes the development and spread of resistant bacteria. It is therefore critical that LTCFs are able to engage in antimicrobial stewardship programmes, which have the potential to minimize the antibiotic selective pressure, while improving the quality of care received by LTCF residents. To date, no antimicrobial stewardship guidelines specific to LTCF settings have been published. Here we outline the scale of antimicrobial use in LTCFs and the underlying drivers for antibiotic over-use. We further describe the particular challenges of antimicrobial stewardship in LTCFs, and review the interventional studies that have aimed to improve antibiotic use in these settings. Practical recommendations are then drawn from this research to help guide the development and implementation of antimicrobial stewardship programmes.
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Affiliation(s)
- O J Dyar
- North Devon District Hospital, Barnstaple, UK
| | - L Pagani
- Bolzano Central Hospital, Infectious Diseases Unit, Bolzano, Italy
| | - C Pulcini
- CHU de Nancy, Service de Maladies Infectieuses, Nancy, France; Université de Lorraine, Université Paris Descartes, EA 4360 Apemac, Nancy, France.
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