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Khan SS, Krichavets I, Feldmesser M. Reaching high-hanging fruit in antimicrobial stewardship: a hospital-based intervention to withdraw inappropriately prescribed antimicrobials. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2024; 4:e42. [PMID: 38628371 PMCID: PMC11019577 DOI: 10.1017/ash.2024.48] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 03/07/2024] [Accepted: 03/07/2024] [Indexed: 04/19/2024]
Abstract
Background Antimicrobial stewardship programs (ASPs) are responsible for addressing unnecessary antimicrobial use. We describe our experience with a unique intervention to withdraw unnecessary antimicrobials. Methods Design, Setting, Participants: descriptive case series of adult inpatients at a single academic medical center, December 2021 to December 2022; Intervention: hospital-wide policy allowing ASP to discontinue inappropriate antimicrobials in select cases not resolved by prospective audit and feedback; Measures: count, date, and generic names of antimicrobials prescribed; reason for antimicrobial withdrawal (prolonged duration, no evidence of infection, or other); withdrawals by inpatient service (surgical or medical); time from antimicrobial start date to withdrawal intervention; days of therapy (DOT) saved; "nudge effect" defined as the prescribing team self-discontinuing withdrawn antimicrobial within 24 hours of withdrawal notice; appeals to withdrawals; ordering of alternative antimicrobials following withdrawal; incident infections, readmission, in-hospital mortality within 30 days of withdrawal intervention. Results There were 54 antimicrobials withdrawn among 36 unique patients during the study period; piperacillin-tazobactam followed by vancomycin were the most frequently withdrawn agents; prolonged duration of therapy or prophylaxis followed by no evidence of infection were the most common reasons for withdrawal; withdrawals occurred most often on surgical services; an estimated 236 DOT (27.2 DOT per 100 patient-days) were saved; 32% of withdrawals were appealed; alternative antimicrobials were ordered following 20% of withdrawals; no incident infections, readmissions or in-hospital deaths were definitively attributed to withdrawal intervention. Conclusions Our antimicrobial withdrawal intervention was a safe and effective addition to ASP activities to reduce inappropriate antimicrobial use and improve prescriber accountability.
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Affiliation(s)
- Salman S. Khan
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
- Division of Infectious Diseases, Lenox Hill Hospital, New York, NY, USA
| | - Ilya Krichavets
- Department of Pharmacy, Lenox Hill Hospital, New York, NY, USA
| | - Marta Feldmesser
- Division of Infectious Diseases, Lenox Hill Hospital, New York, NY, USA
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Nielsen ND, Dean JT, Shald EA, Conway Morris A, Povoa P, Schouten J, Parchim N. When to Stop Antibiotics in the Critically Ill? Antibiotics (Basel) 2024; 13:272. [PMID: 38534707 DOI: 10.3390/antibiotics13030272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 03/03/2024] [Accepted: 03/14/2024] [Indexed: 03/28/2024] Open
Abstract
Over the past century, antibiotic usage has skyrocketed in the treatment of critically ill patients. There have been increasing calls to establish guidelines for appropriate treatment and durations of antibiosis. Antibiotic treatment, even when appropriately tailored to the patient and infection, is not without cost. Short term risks-hepatic/renal dysfunction, intermediate effects-concomitant superinfections, and long-term risks-potentiating antimicrobial resistance (AMR), are all possible consequences of antimicrobial administration. These risks are increased by longer periods of treatment and unnecessarily broad treatment courses. Recently, the literature has focused on multiple strategies to determine the appropriate duration of antimicrobial therapy. Further, there is a clinical shift to multi-modal approaches to determine the most suitable timepoint at which to end an antibiotic course. An approach utilising biomarker assays and an inter-disciplinary team of pharmacists, nurses, physicians, and microbiologists appears to be the way forward to develop sound clinical decision-making surrounding antibiotic treatment.
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Affiliation(s)
- Nathan D Nielsen
- Division of Pulmonary, Critical Care and Sleep Medicine, University of New Mexico School of Medicine, Albuquerque, NM 87131, USA
- Section of Transfusion Medicine and Therapeutic Pathology, University of New Mexico School of Medicine, Albuquerque, NM 87131, USA
| | - James T Dean
- Division of Pulmonary, Critical Care and Sleep Medicine, University of New Mexico School of Medicine, Albuquerque, NM 87131, USA
| | - Elizabeth A Shald
- Department of Pharmacy, University of New Mexico Hospital, Albuquerque, NM 87131, USA
| | - Andrew Conway Morris
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge CB2 0QQ, UK
- Division of Immunology, Department of Pathology, University of Cambridge, Cambridge CB2 1QP, UK
- JVF Intensive Care Unit, Addenbrooke's Hospital, Cambridge CB2 0QQ, UK
| | - Pedro Povoa
- NOVA Medical School, NOVA University of Lisbon, 1169-056 Lisbon, Portugal
- Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, OUH Odense University Hospital, 5000 Odense, Denmark
- Department of Intensive Care, Hospital de São Francisco Xavier, CHLO, 1449-005 Lisbon, Portugal
| | - Jeroen Schouten
- Department of Intensive Care Medicine, Radboud MC, 6525 GA Nijmegen, The Netherlands
| | - Nicholas Parchim
- Division of Critical Care, Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, NM 87131, USA
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3
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L A Cross E, Quan TP, Hayward GN, Walker AS, Llewelyn MJ. Development and validation of the Baseline Recurrence Risk in Cellulitis (BRRISC) score. J Infect 2024; 88:103-111. [PMID: 38128701 DOI: 10.1016/j.jinf.2023.12.007] [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: 01/04/2023] [Revised: 11/16/2023] [Accepted: 12/14/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVES Cellulitis is often treated with antibiotics for longer than recommended by guidelines. Prolonged therapy may reduce recurrence in certain patients, but it is not known which patients are at greatest risk. Our objective was to develop and temporally validate a risk prediction score to identify patients attending hospital with cellulitis at highest risk of recurrence. METHODS We included UK adult patients with cellulitis attending hospital in an electronic health records (EHR) study to identify demographic, comorbid, physiological, and laboratory factors predicting recurrence (before death) within 90 days, using multivariable logistic regression with backwards elimination in complete cases. A points-based risk score integerised model coefficients for selected predictors. Performance was assessed using the C-index in development and temporal validation samples. RESULTS The final model included 4938 patients treated for median 8 days (IQR 6-11); 8.8% (n = 436) experienced hospitalisation-associated recurrence. A risk score using eight variables (age, heart rate, urea, platelets, albumin, previous cellulitis, venous insufficiency, and liver disease) ranged from 0-15, with C-index = 0.65 (95%CI: 0.63-0.68). Categorising as low (score 0-1), medium (2-5) and high (6-15) risk, recurrence increased fourfold; 3.2% (95%CI: 2.3-4.4%), 9.7% (8.7-10.8%), and 16.6% (13.3-20.4%). Performance was maintained in the validation sample (C-index = 0.63 (95%CI: 0.58-0.67)). Among patients at high risk, four distinct clinical phenotypes were identified using hierarchical clustering 1) young, acutely unwell with liver disease; 2) comorbid with previous cellulitis and venous insufficiency; 3) chronic renal disease with severe renal impairment; and 4) acute severe illness, with substantial inflammatory responses. CONCLUSIONS Risk of cellulitis recurrence varies markedly according to individual patient factors captured in the Baseline Recurrence Risk in Cellulitis (BRRISC) score. Further work is needed to optimise the score, considering baseline and treatment response variables not captured in EHR data, and establish the utility of risk-based approaches to guide optimal antibiotic duration.
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Affiliation(s)
- Elizabeth L A Cross
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Falmer BN1 9PS, UK
| | - T Phuong Quan
- Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Headley Way, Oxford OX3 9DU, UK; NIHR Biomedical Research Centre, Oxford OX3 9DU, UK; National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford OX3 9DU, UK
| | - Gail N Hayward
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Rd, Oxford OX2 6GG, UK
| | - A Sarah Walker
- Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Headley Way, Oxford OX3 9DU, UK; NIHR Biomedical Research Centre, Oxford OX3 9DU, UK; National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford OX3 9DU, UK
| | - Martin J Llewelyn
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Falmer BN1 9PS, UK.
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Henley J, Brookes-Howell L, Euden J, Pallmann P, Llewelyn M, Howard P, Powell N, Dark P, Szakmany T, Hellyer TP, Albur M, Hamilton R, Prestwich G, Ogden M, Maboshe W, Sandoe J, Thomas-Jones E, Carrol E. Developing a model for decision-making around antibiotic prescribing for patients with COVID-19 pneumonia in acute NHS hospitals during the first wave of the COVID-19 pandemic: qualitative results from the Procalcitonin Evaluation of Antibiotic use in COVID-19 Hospitalised patients (PEACH Study). BMJ Open 2023; 13:e077117. [PMID: 38114276 DOI: 10.1136/bmjopen-2023-077117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2023] Open
Abstract
OBJECTIVE To explore and model factors affecting antibiotic prescribing decision-making early in the pandemic. DESIGN Semistructured qualitative interview study. SETTING National Health Service (NHS) trusts/health boards in England and Wales. PARTICIPANTS Clinicians from NHS trusts/health boards in England and Wales. METHOD Individual semistructured interviews were conducted with clinicians in six NHS trusts/health boards in England and Wales as part of the Procalcitonin Evaluation of Antibiotic use in COVID-19 Hospitalised patients study, a wider study that included statistical analysis of procalcitonin (PCT) use in hospitals during the first wave of the pandemic. Thematic analysis was used to identify key factors influencing antibiotic prescribing decisions for patients with COVID-19 pneumonia during the first wave of the pandemic (March to May 2020), including how much influence PCT test results had on these decisions. RESULTS During the first wave of the pandemic, recommendations to prescribe antibiotics for patients with COVID-19 pneumonia were based on concerns about secondary bacterial infections. However, as clinicians gained more experience with COVID-19, they reported increasing confidence in their ability to distinguish between symptoms and signs caused by SARS-CoV-2 viral infection alone, and secondary bacterial infections. Antibiotic prescribing decisions were influenced by factors such as clinician experience, confidence, senior support, situational factors and organisational influences. A decision-making model was developed. CONCLUSION This study provides insight into the decision-making process around antibiotic prescribing for patients with COVID-19 pneumonia during the first wave of the pandemic. The importance of clinician experience and of senior review of decisions as factors in optimising antibiotic stewardship is highlighted. In addition, situational and organisational factors were identified that could be optimised. The model presented in the study can be used as a tool to aid understanding of the complexity of the decision-making process around antibiotic prescribing and planning antimicrobial stewardship support in the context of a pandemic. TRIAL REGISTRATION NUMBER ISRCTN66682918.
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Affiliation(s)
- Josie Henley
- School of Social Sciences, Cardiff University, Cardiff, UK
| | | | - Joanne Euden
- College of Biomedical and Life Sciences, Cardiff University Centre for Trials Research, Cardiff, UK
| | - Philip Pallmann
- College of Biomedical and Life Sciences, Cardiff University Centre for Trials Research, Cardiff, UK
| | - Martin Llewelyn
- Brighton and Sussex Medical School, University of Sussex and University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Philip Howard
- School of Healthcare, University of Leeds, Leeds, UK
- Pharmacy, Leeds Teaching Hospitals, Leeds, UK
| | - Neil Powell
- Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - Paul Dark
- Intensive Care Unit, University of Manchester, Salford, UK
| | - Tamas Szakmany
- Critical Care Directorate, Aneurin Bevan University Health Board, Newport, UK
- Department of Anaesthesia, Intensive Care and Pain Medicine, Division of Population Medicine, Cardiff Univeristy, Cardiff, UK
| | - Thomas P Hellyer
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | | | - Ryan Hamilton
- School of Pharmacy, De Montfort University, Leicester, UK
| | | | - Margaret Ogden
- Faculty of Social Sciences, University of Stirling, Stirling, UK
| | | | - Jonathan Sandoe
- Department of Microbiology, The General Infirmary at Leeds, Leeds, UK
- Healthcare Associated Infection Group, Leeds Institute of Medical Research, University of Leeds, Leeds, UK
| | | | - Enitan Carrol
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
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Owens R, Bamford K, Pinion S, Garry E, Cranmer E, Pearce C, Wint HH, Gill S, Philips R, Khan A, Roy Bentley S, Roberts N, Keating B, Askaroff N, Morphew M, Orr C, Mouket T, Pope K, Powell N. Assessment of the appropriateness of antibiotic prescribing in an acute UK hospital using a national audit tool: a single centre retrospective survey. Eur J Hosp Pharm 2023:ejhpharm-2022-003569. [PMID: 37117009 DOI: 10.1136/ejhpharm-2022-003569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 03/28/2023] [Indexed: 04/30/2023] Open
Abstract
INTRODUCTION Antibiotic use drives antibiotic resistance. The UK antimicrobial resistance (AMR) strategy aims to reduce antibiotic use. We aimed to quantify excess antibiotic use in a district general hospital in south-west England. METHODS Medical patients discharged in August 2020 who had received antibiotics were included. An audit tool of antibiotic prescribing appropriateness was used to collect relevant clinical information regarding each patient case. The appropriateness of antibiotic use was then determined by two infection specialists and excess days of therapy (DOTs) calculated. RESULTS 647 patients were discharged in August 2020. Of the 1658 antibiotic DOTs for the 184 patients reviewed, 403 (24%) were excess DOTs. The excess antibiotic DOTs were prescribed in 92 patients (50%); 112/403 (27.8%) excess DOTs originated at the initiation of antibiotic therapy (time point A); 184/403 (45.7%) of excess DOTs occurred at the antibiotic review pre-72 hours (time point B); and 107/403 (26.6%) of excess DOTs were due to protracted antibiotic courses (time point C). CONCLUSION 24% of antibiotic DOTs were deemed unnecessary. The greatest opportunity to reduce antibiotic use safely was the pre-72 hours antibiotic review, which may provide a target for reducing excess antimicrobial therapy in line with the national AMR strategy.
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Affiliation(s)
- Rhys Owens
- Emergency Department, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Kathy Bamford
- Medical Microbiology, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Sophie Pinion
- Anaesthetics, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Emma Garry
- Department of Obstetrics and Gynaecology, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Emily Cranmer
- Eldercare, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Catharine Pearce
- Respiratory department, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Htet Htet Wint
- Neurology department, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Simon Gill
- Respiratory department, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Ryan Philips
- Acute Medicine, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Adnan Khan
- Eldercare, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Selina Roy Bentley
- Enhanced Perioperative Care Unit, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Neil Roberts
- University Hositals Plymouth NHS Trust, Plymouth, UK
| | | | - Natasha Askaroff
- Oncology Department, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Megan Morphew
- Oncology, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Charles Orr
- Emergency Department, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Tarek Mouket
- Acute Medicine, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Katherine Pope
- Acute Medicine, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
| | - Neil Powell
- Pharmacy Department, Royal Cornwall Hospital NHS Trust, Cornwall, UK
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6
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Dorgali MV, Longo A, Vass C, Shields G, Harrison R, Scarpa R, Boeri M. A General Public Study on Preferences and Welfare Impacts of Antimicrobial Resistance in the United Kingdom. PHARMACOECONOMICS 2022; 40:65-76. [PMID: 34458962 PMCID: PMC8403518 DOI: 10.1007/s40273-021-01076-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/01/2021] [Indexed: 05/09/2023]
Abstract
BACKGROUND Antibiotics have led to considerable increases in life expectancy. However, over time, antimicrobial resistance has accelerated and is now a significant global public health concern. Understanding societal preferences for the use of antibiotics as well as eliciting the willingness to pay for future research is crucial. OBJECTIVE To investigate preferences for different strategies to optimize antibiotic use and to understand the willingness to pay for future research in antimicrobial resistance and antimicrobial drug development. METHODS A discrete-choice experiment was administered to a sample of the UK general population. Respondents were asked to make nine choices, each offering three options-two hypothetical "doctor and antibiotics" and one "no doctor-no antibiotics"-defined by five attributes: treatment, days needed to recover, risk of bacterial infection that needs antibiotics, risk of common side effects, and risk of antimicrobial resistance by 2050. Data were analyzed using random parameters logit models. A double-bounded contingent valuation was also included in the survey to explore the willingness to pay for policies to contain antimicrobial resistance. RESULTS Among the 2579 respondents who completed the survey, 1151 always selected "no doctor-no antibiotics" and 57 never varied their choices; therefore, 1371 responses were used in the analysis. Risk of antimicrobial resistance by 2050 was the most important attribute and the "treatment" was the least important attribute, although this was sensitive to a higher risk of bacterial infection. The aggregate annual willingness to pay for containing antimicrobial resistance was approximately £8.35 billion (~£5-£10 billion). CONCLUSIONS The antimicrobial resistance risk is relevant and important to the general public. The high willingness to pay suggests that large investments in policies or interventions to combat antimicrobial resistance are justified.
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Affiliation(s)
- Maria Veronica Dorgali
- Queen's University Belfast, Belfast, UK
- Department Statistics, Informatics, Application "G. Parenti" (DISIA), University of Florence, Florence, Italy
| | | | - Caroline Vass
- RTI Health Solutions, RTI International, Manchester, UK
- Division of Population Health, Health Services Research & Primary Care, The University of Manchester, Manchester, UK
| | - Gemma Shields
- Division of Population Health, Health Services Research & Primary Care, The University of Manchester, Manchester, UK
| | - Roger Harrison
- Division of Population Health, Health Services Research & Primary Care, The University of Manchester, Manchester, UK
| | | | - Marco Boeri
- Queen's University Belfast, Belfast, UK.
- RTI Health Solutions, RTI International, Forsyth House, Cromac Square, Belfast, BT2 8LA, UK.
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Janssen RME, Oerlemans AJM, Van Der Hoeven JG, Ten Oever J, Schouten JA, Hulscher MEJL. OUP accepted manuscript. J Antimicrob Chemother 2022; 77:2105-2119. [PMID: 35612930 PMCID: PMC9333408 DOI: 10.1093/jac/dkac162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 05/02/2022] [Indexed: 11/14/2022] Open
Abstract
Background In daily hospital practice, antibiotic therapy is commonly prescribed for longer than recommended in guidelines. Understanding the key drivers of prescribing behaviour is crucial to generate meaningful interventions to bridge this evidence-to-practice gap. Objectives To identify behavioural determinants that might prevent or enable improvements in duration of antibiotic therapy in daily practice. Methods We systematically searched PubMed, Embase, PsycINFO and Web of Science for relevant studies that were published between January 2000 and August 2021. All qualitative, quantitative and mixed-method studies in adults in a hospital setting that reported determinants of antibiotic therapy duration were included. Results Twenty-two papers were included in this review. A first set of studies provided 82 behavioural determinants that shape how health professionals make decisions about duration; most of these were related to individual health professionals’ knowledge, skills and cognitions, and to professionals’ interactions. A second set of studies provided 17 determinants that point to differences in duration regarding various pathogens, diseases, or patient, professional or hospital department characteristics, but do not explain why or how these differences occur. Conclusions Limited literature is available describing a wide range of determinants that influence duration of antibiotic therapy in daily practice. This review provides a stepping stone for the development of stewardship interventions to optimize antibiotic therapy duration, but more research is warranted. Stewardship teams must develop complex improvement interventions to address the wide variety of behavioural determinants, adapted to the specific pathogen, disease, patient, professional and/or hospital department involved.
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Affiliation(s)
| | - Anke J M Oerlemans
- Scientific Center for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Johannes G Van Der Hoeven
- Department of Intensive Care Medicine, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jaap Ten Oever
- Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Internal Medicine, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jeroen A Schouten
- Department of Intensive Care Medicine, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- Scientific Center for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marlies E J L Hulscher
- Scientific Center for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands
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Broom J, Broom A, Kenny K, Post JJ, Konecny P. Institutional governance and responsiveness to antimicrobial resistance: a qualitative study of Australian hospital executives. BMJ Open 2021; 11:e055215. [PMID: 34862300 PMCID: PMC8647559 DOI: 10.1136/bmjopen-2021-055215] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVES Despite escalating antimicrobial resistance (AMR), implementing effective antimicrobial optimisation within healthcare settings has been hampered by institutional impediments. This study sought to examine, from a hospital management and governance perspective, why healthcare providers may find it challenging to enact changes needed to address rising AMR. DESIGN Semistructured qualitative interviews around their experiences of antimicrobial stewardship (AMS) and responsiveness to the requirement for optimisation. Data were analysed using the framework approach. SETTING Two metropolitan tertiary-referral hospitals in Australia. PARTICIPANTS Twenty hospital managers and executives from the organisational level of department head and above, spanning a range of professional backgrounds and in both clinical and non-clinical roles, and different professional streams were represented. RESULTS Thematic analysis demonstrated three key domains which managers and executives describe, and which might function to delimit institutional responsiveness to present and future AMR solutions. First, the primacy of 'political' priorities. AMR was perceived as a secondary priority, overshadowed by political priorities determined beyond the hospital by state health departments/ministries and election cycles. Second, the limits of accreditation as a mechanism for change. Hospital accreditation processes and regulatory structures were not sufficient to induce efficacious AMS. Third, a culture of acute problem 'solving' rather than future proofing. A culture of reactivity was described across government and healthcare institutions, precluding longer term objectives, like addressing the AMR crisis. CONCLUSION There are dynamics between political and health service institutions, as well as enduring governance norms, that may significantly shape capacity to enact AMS and respond to AMR. Until these issues are addressed, and the field moves beyond individual behaviour modification models, antimicrobial misuse will likely continue, and stewardship is likely to have a limited impact.
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Affiliation(s)
- Jennifer Broom
- Infectious Diseases Service, Sunshine Coast University Hospital, Sunshine Coast, Queensland, Australia
- School of Biomedical Sciences, The University of Queensland, Herston, Queensland, Australia
| | - Alex Broom
- Sydney Centre for Healthy Societies, School of Social and Political Sciences, University of Sydney, Sydney, New South Wales, Australia
| | - Katherine Kenny
- Sydney Centre for Healthy Societies, School of Social and Political Sciences, University of Sydney, Sydney, New South Wales, Australia
| | - Jeffrey J Post
- Department of Infectious Diseases, Prince of Wales Hospital and Community Health Services, Randwick, New South Wales, Australia
- Prince of Wales Clinical School, University of New South Wales, Randwick, New South Wales, Australia
| | - Pamela Konecny
- Department of Infectious Diseases, Immunology & Sexual Health, St George Hospital, Sydney, New South Wales, Australia
- St George and Sutherland Clinical School, University of New South Wales, Sydney, New South Wales, Australia
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Benavides JA, Streicker DG, Gonzales MS, Rojas-Paniagua E, Shiva C. Knowledge and use of antibiotics among low-income small-scale farmers of Peru. Prev Vet Med 2021; 189:105287. [PMID: 33677408 PMCID: PMC8636688 DOI: 10.1016/j.prevetmed.2021.105287] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 01/12/2021] [Accepted: 01/24/2021] [Indexed: 12/28/2022]
Abstract
The extensive use and misuse of antibiotics in the livestock sector is one of the main drivers of the emergence and spread of antimicrobial resistance. Although small-scale farms constitute most of the livestock production in low and middle-income countries, knowledge and use of antibiotics among these populations is sparse. We conducted 201 questionnaires to estimate the use and knowledge of antibiotics by small-scale farmers located in the coastal area of the Lima region of Peru. Our results show that farmers had a small number of livestock (e.g. average of 11 cows, 7 pigs and 19 chickens per farm) and 80 % earned less than minimum wage. More than half of farmers reported at least one episode of respiratory disease, diarrhea, mastitis, skin lesion or post-parturition infection in their animals during the previous year, and 40 % of these episodes were treated with antibiotics. Farmers reported using 14 different antibiotics, most commonly oxytetracycline (31 % of episodes treated with antibiotics), penicillin (21 %), gentamicin (19 %) and trimethoprim-sulfamethazine (18 %). The third-generation cephalosporin ceftiofur was occasionally used to treat mastitis. Most farmers relied on veterinarians to prescribe (95 % of respondents) and administer (59 %) antibiotics. Only half of farmers knew what micro-organisms can be treated with antibiotics and the degree of knowledge of antibiotics (based on a 5-question metric) was positively correlated with respondents’ educational level, monthly income, knowledge of the animal health authority, farm area, number of cows and knowledge of an antiparasitic drug. In contrast, knowledge of antibiotics was not correlated with respondents’ age, gender, main occupation, knowledge of a veterinarian or household size. Potential misuse of antibiotics was reported, including 21 % of framers reporting stopping the treatment when clinical signs disappear and infrequent use of antibiotics to treat parasites or animals not eating. Our study highlights poor knowledge and potential misuse of antibiotics among small-scale farmers in coastal Peru, but high reliance on veterinarians for prescription and administration. Strengthening farmers' relationships with veterinarians and improving the diagnostic capacity of the veterinary sector could result in more judicious antibiotic use on these farms.
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Affiliation(s)
- Julio A Benavides
- Departamento de Ecología y Biodiversidad, Facultad de Ciencias de la Vida, Universidad Andrés Bello, Santiago, Chile; Institute of Biodiversity, Animal Health and Comparative Medicine, College of Medical Veterinary and Life Sciences, University of Glasgow, Graham Kerr Building, Glasgow, Scotland, UK; Centro de Investigación para la Sustentabilidad, Facultad de Ciencias de la Vida, Universidad Andrés Bello, Santiago, Chile; Millennium Nucleus for Collaborative Research on Bacterial Resistance MICROB-R, Santiago, Chile.
| | - Daniel G Streicker
- Institute of Biodiversity, Animal Health and Comparative Medicine, College of Medical Veterinary and Life Sciences, University of Glasgow, Graham Kerr Building, Glasgow, Scotland, UK; MRC-University of Glasgow Centre for Virus Research, Glasgow, UK
| | - Milagros S Gonzales
- Facultad de Medicina Veterinaria y Zootecnia de la Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Elizabeth Rojas-Paniagua
- Facultad de Medicina Veterinaria y Zootecnia de la Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Carlos Shiva
- Facultad de Medicina Veterinaria y Zootecnia de la Universidad Peruana Cayetano Heredia, Lima, Peru
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Miller L, Costelloe CE, Robotham JV, Pouwels KB. Overuse of antibiotics: Can viral vaccinations help stem the tide? Br J Clin Pharmacol 2020; 87:87-89. [PMID: 33207008 PMCID: PMC7753246 DOI: 10.1111/bcp.14651] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 10/16/2020] [Accepted: 11/03/2020] [Indexed: 02/05/2023] Open
Affiliation(s)
- Lucy Miller
- Global Digital Health Unit, Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Ceire E Costelloe
- Global Digital Health Unit, Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Julie V Robotham
- HCAI and AMR Division, National Infection Service, Public Health England, London, UK
| | - Koen B Pouwels
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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