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Linde-Ozola Z, Classen AY, Giske CG, Göpel S, Eliakim-Raz N, Semret M, Simonsen GS, Vehreschild JJ, Jørgensen SB, Kessel J, Kleppe LKS, Oma DH, Vehreschild MJGT, Vilde A, Dumpis U. Quality, availability and suitability of antimicrobial stewardship guidance: a multinational qualitative study. JAC Antimicrob Resist 2024; 6:dlae039. [PMID: 38486662 PMCID: PMC10939443 DOI: 10.1093/jacamr/dlae039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 02/19/2024] [Indexed: 03/17/2024] Open
Abstract
Background Antimicrobial stewardship (AMS) programmes are established across the world to treat infections efficiently, prioritize patient safety, and reduce the emergence of antimicrobial resistance. One of the core elements of AMS programmes is guidance to support and direct physicians in making efficient, safe and optimal decisions when prescribing antibiotics. To optimize and tailor AMS, we need a better understanding of prescribing physicians' experience with AMS guidance. Objectives To explore the prescribing physicians' user experience, needs and targeted improvements of AMS guidance in hospital settings. Methods Semi-structured interviews were conducted with 36 prescribing physicians/AMS guidance users from hospital settings in Canada, Germany, Israel, Latvia, Norway and Sweden as a part of the international PILGRIM trial. A socioecological model was applied as an overarching conceptual framework for the study. Results Research participants were seeking more AMS guidance than is currently available to them. The most important aspects and targets for improvement of AMS guidance were: (i) quality of guidelines; (ii) availability of infectious diseases specialists; and (iii) suitability of AMS guidance to department context. Conclusions Achieving prudent antibiotic use not only depends on individual and collective levels of commitment to follow AMS guidance but also on the quality, availability and suitability of the guidance itself. More substantial commitment from stakeholders is needed to allocate the required resources for delivering high-quality, available and relevant AMS guidance to make sure that the prescribers' AMS needs are met.
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Affiliation(s)
| | - Annika Y Classen
- Faculty of Medicine, University of Cologne, Cologne, Germany
- Department I for Internal Medicine, University Hospital Cologne, Cologne, Germany
- German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany
| | - Christian G Giske
- Department of Laboratory Medicine, Karolinska Institute, Stockholm, Sweden
- Department of Clinical Microbiology, Karolinska University Hospital, Stockholm, Sweden
| | - Siri Göpel
- Department of Internal Medicine I, Division of infectious diseases, University Hospital Tübingen, Tübingen, Germany
- Clinical Research Unit for Healthcare Associated and Antibiotic Resistant Bacterial Infections, German Centre for Infection Research (DZIF), Tübingen, Germany
| | - Noa Eliakim-Raz
- Internal Medicine E, Rabin Medical Center Beilinson Campus, Petah-Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Makeda Semret
- Infectious Diseases and Medical Microbiology, McGill University Health Centre, Montreal, Canada
| | - Gunnar Skov Simonsen
- Department of Microbiology and Infection Control, University Hospital of North Norway, Tromsø, Norway
- UiT-The Arctic University of Norway, Tromsø, Norway
| | - Jörg Janne Vehreschild
- Faculty of Medicine, University of Cologne, Cologne, Germany
- Department I for Internal Medicine, University Hospital Cologne, Cologne, Germany
- German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany
- Department II of Internal Medicine, Haematology/Oncology, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Silje Bakken Jørgensen
- Department of Medical Microbiology and Infection Control and Department of Emergency Care, Akershus University Hospital, Lørenskog, Norway
| | - Johanna Kessel
- Department of Internal Medicine, Infectious Diseases, Goethe University Frankfurt, Frankfurt Am Main, Germany
| | - Lars Kåre Selland Kleppe
- Department of Infection Prevention and Control, Stavanger University Hospital, Stavanger, Norway
| | - Dorthea Hagen Oma
- Section for Patient Safety, Haukeland University Hospital, Bergen, Norway
| | - Maria J G T Vehreschild
- Faculty of Medicine, University of Cologne, Cologne, Germany
- Department I for Internal Medicine, University Hospital Cologne, Cologne, Germany
- German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany
- Department of Internal Medicine, Infectious Diseases, Goethe University Frankfurt, Frankfurt Am Main, Germany
| | - Aija Vilde
- Faculty of Medicine, University of Latvia, Riga, Latvia
- Pauls Stradins Clinical University Hospital, Riga, Latvia
| | - Uga Dumpis
- Faculty of Medicine, University of Latvia, Riga, Latvia
- Pauls Stradins Clinical University Hospital, Riga, Latvia
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Payton KSE, Gould JB. Vignette Research Methodology: An Essential Tool for Quality Improvement Collaboratives. Healthcare (Basel) 2022; 11:healthcare11010007. [PMID: 36611468 PMCID: PMC9818599 DOI: 10.3390/healthcare11010007] [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: 11/16/2022] [Revised: 12/11/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022] Open
Abstract
Variation in patient outcomes among institutions and within institutions is a major problem in healthcare. Some of this variation is due to differences in practice, termed practice variation. Some practice variation is expected due to appropriately personalized care for a given patient. However, some practice variation is due to the individual preference or style of the clinicians. Quality improvement collaboratives are commonly used to disseminate quality care on a wide scale. Practice variation is a notable barrier to any quality improvement effort. A detailed and accurate understanding of practice variation can help optimize the quality improvement efforts. The traditional survey methods do not capture the complex nuances of practice variation. Vignette methods have been shown to accurately measure the actual practice variation and quality of care delivered by clinicians. Vignette methods are cost-effective relative to other methods of measuring quality of care. This review describes our experience and lessons from implementing vignette research methods in quality improvement collaboratives in California neonatal intensive care units. Vignette methodology is an ideal tool to address practice variation in quality improvement collaboratives, actively engage a large number of participants, and support more evidence-based practice to improve outcomes.
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Affiliation(s)
- Kurlen S. E. Payton
- Cedars-Sinai Medical Center, Department of Pediatrics, Division of Neonatology, Los Angeles, CA 90048, USA
- California Perinatal Quality Care Collaborative, Stanford, CA 94305, USA
- Correspondence:
| | - Jeffrey B. Gould
- California Perinatal Quality Care Collaborative, Stanford, CA 94305, USA
- Department of Pediatrics, Division of Neonatology, Stanford University, Stanford, CA 94305, USA
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Rynkiewich K. Antimicrobial prescribing matters: the irreconcilability in moral ranking systems. Anthropol Med 2022; 29:208-222. [PMID: 35240888 DOI: 10.1080/13648470.2021.1994331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Antimicrobial resistance caused by widespread use of antimicrobials is a defining challenge of our time. This article presents antimicrobial prescribing among physicians as a morally irreconcilable endeavour. Particularly, the physician may have no good option when antimicrobial resistance is seen as both (1) a global threat to be addressed at the population level, and (2) a threat to the individual patient to be addressed in clinical practice. This research demonstrates that in practice, the physician is presented with an irreconcilable dilemma between caring for the population or caring for the individual. The author utilizes an extended ethnographic case study of infectious disease specialists to show that physicians are pressured to use antimicrobials more responsibly for the benefit of society, yet at the same time treat the individual patients with care by administering the most effective and appropriate agents. The author concludes by suggesting that there is no straightforward answer for the practicing physician, since what ultimately matters is unlikely to satisfy either moral ranking system.
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Skjølstrup NK, Lastein DB, Jensen CS, Vaarst M. The antimicrobial landscape as outlined by Danish dairy farmers. J Dairy Sci 2021; 104:11147-11164. [PMID: 34364645 DOI: 10.3168/jds.2021-20552] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 06/21/2021] [Indexed: 11/19/2022]
Abstract
Limiting antimicrobial use (AMU) in dairy farming is an important step toward reducing antimicrobial resistance (AMR). Therefore, it is relevant to understand dairy farmers' choices and the potential for change in relation to AMU, even in countries with low usage. Furthermore, there is an increasing recognition of the need to focus on both the individual farmer's behavior as well as the context surrounding and influencing the farmer's decisions in relation to AMU if the goal is further reduction. To date, no studies have taken into account both the individual farmer and their context in both conventional and organic dairy farms under Danish conditions. For this study, 15 Danish dairy farmers were interviewed using qualitative semi-structured research interviews, and the notion of landscape was used to describe the context of their AMU. We found that AMR was considered a distant element of the farmers' antimicrobial landscape. Daily challenges such as acutely diseased animals and poor housing conditions seemed more urgent and overruled the threat of AMR. We also found that interviewed farmers had differing opinions on farm management, partly shaped by changes in legislation and ways of farming over time. At one end of the scale, some organic farmers had rethought the current way of farming; keeping robust animals in a natural setting was expected to prevent disease. They were positive about legislation, and the numerous restrictions on AMU over time were thought to contribute to ensuring quality for consumers. At the other end of the scale, some conventional farmers perceived disease as something that should be controlled through treatment, and the currently eased legislation and intensification of farming have legitimatized AMU for this purpose, leading to an expectation among these farmers of certain rights to handle medicines themselves. These contrasting views might lead to inspiration and competition in terms of reducing AMU, as the farmers appeared to value the opinions of other farmers, and they were found to continuously assess each other. Through such ongoing assessment, pioneers of AMU reduction-whether organic or conventional-might motivate their colleagues to change their AMU. Future research should address the potential of experience- and attitude-sharing among farmers as motivation to reduce AMU.
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Affiliation(s)
- Nanna K Skjølstrup
- Section for Production, Nutrition and Health, Department of Veterinary and Animal Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, 1870 Frederiksberg, Denmark.
| | - Dorte B Lastein
- Section for Production, Nutrition and Health, Department of Veterinary and Animal Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, 1870 Frederiksberg, Denmark
| | - Carsten S Jensen
- Department of Sociology, Faculty of Social Sciences, University of Copenhagen, 1353 Copenhagen, Denmark
| | - Mette Vaarst
- Department of Animal Sciences, Aarhus University, 8830 Tjele, Denmark
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Skjølstrup NK, Nielsen LR, Jensen CS, Lastein DB. Veterinary Herd Health Consultancy and Antimicrobial Use in Dairy Herds. Front Vet Sci 2021; 7:547975. [PMID: 33604361 PMCID: PMC7884328 DOI: 10.3389/fvets.2020.547975] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 12/14/2020] [Indexed: 01/21/2023] Open
Abstract
The globally increasing level of antimicrobial resistance affects both human and animal health, why it is necessary to identify ways to change our current use of antimicrobials. The veterinary herd health collaboration between veterinarians and dairy farmers provides a useful setting for changing antimicrobial use in livestock. However, farmers and veterinarians work in a complex agricultural setting influenced by socio-economic factors, which complicates their choices regarding antimicrobial usage. It is therefore necessary to be aware of the range of potential influencing factors and to integrate this knowledge in the relevant local settings. This manuscript presents a literature review of relevant factors relating to antimicrobial use within the veterinary herd health consultancy setting, including knowledge gaps of relevance for changing the use of antimicrobials. An enriched version of the framework of the Theory of Planned Behaviour was used to organise the literature review. We identified diverging attitudes on correct treatment practices and perceptions of antimicrobial resistance among veterinarians and farmers, influenced by individual risk perception as well as social norms. Furthermore, disagreements in terms of goal setting and in the frequency of herd visits in relation to herd health consultancy can negatively influence the collaboration and the intention to change antimicrobial use. Farmers and veterinarians emphasise the importance of legislation and the role of the dairy industry in changing antimicrobial use, but the relevance of specific factors depends on the country-specific context. Overall, farmers and veterinarians must communicate better to understand each other's perspectives and establish common goals within the collaboration if they are to work efficiently to reduce antimicrobial use. Farmers and veterinarians both requested changes in individual behaviour; however, they also called for national and structural solutions in terms of balanced legislation and the availability of better diagnostics to facilitate a change in antimicrobial use practices. These various paths to achieving the desired changes in antimicrobial use illustrate the need to bridge methodological research approaches of veterinary science and social sciences for a better understanding of our potential to change antimicrobial use within the dairy farm animal sector.
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Affiliation(s)
- Nanna K. Skjølstrup
- Section for Production, Nutrition and Health, Department of Veterinary and Animal Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Frederiksberg, Denmark
| | - Liza R. Nielsen
- Section for Animal Welfare and Disease Control, Department of Veterinary and Animal Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Frederiksberg, Denmark
| | - Carsten S. Jensen
- Department of Sociology, Faculty of Social Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Dorte B. Lastein
- Section for Production, Nutrition and Health, Department of Veterinary and Animal Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Frederiksberg, Denmark
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Tarrant C, Colman AM, Jenkins DR, Chattoe-Brown E, Perera N, Mehtar S, Nakkawita WD, Bolscher M, Krockow EM. Drivers of Broad-Spectrum Antibiotic Overuse across Diverse Hospital Contexts-A Qualitative Study of Prescribers in the UK, Sri Lanka and South Africa. Antibiotics (Basel) 2021; 10:94. [PMID: 33477994 PMCID: PMC7835907 DOI: 10.3390/antibiotics10010094] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 01/08/2021] [Accepted: 01/18/2021] [Indexed: 01/02/2023] Open
Abstract
Antimicrobial stewardship programs focus on reducing overuse of broad-spectrum antibiotics (BSAs), primarily through interventions to change prescribing behavior. This study aims to identify multi-level influences on BSA overuse across diverse high and low income, and public and private, healthcare contexts. Semi-structured interviews were conducted with 46 prescribers from hospitals in the UK, Sri Lanka, and South Africa, including public and private providers. Interviews explored decision making about prescribing BSAs, drivers of the use of BSAs, and benefits of BSAs to various stakeholders, and were analyzed using a constant comparative approach. Analysis identified drivers of BSA overuse at the individual, social and structural levels. Structural drivers of overuse varied significantly across contexts and included: system-level factors generating tensions with stewardship goals; limited material resources within hospitals; and patient poverty, lack of infrastructure and resources in local communities. Antimicrobial stewardship needs to encompass efforts to reduce the reliance on BSAs as a solution to context-specific structural conditions.
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Affiliation(s)
- Carolyn Tarrant
- Department of Health Sciences, University of Leicester, Leicester LE1 7RH, UK
| | - Andrew M. Colman
- Department of Neuroscience, Psychology and Behaviour, University of Leicester, Leicester LE1 7RH, UK; (A.M.C.); (E.M.K.)
| | - David R. Jenkins
- Department of Clinical Microbiology, University Hospitals of Leicester NHS Trust, Leicester LE1 5WW, UK; (D.R.J.); (N.P.)
| | - Edmund Chattoe-Brown
- School of Media, Communication and Sociology, University of Leicester, Leicester LE1 7JA, UK;
| | - Nelun Perera
- Department of Clinical Microbiology, University Hospitals of Leicester NHS Trust, Leicester LE1 5WW, UK; (D.R.J.); (N.P.)
| | - Shaheen Mehtar
- Tygerberg Academic Hospital and Faculty of Health Sciences, Stellenbosch University, Cape Town 7505, South Africa; (S.M.); (M.B.)
| | - W.M.I. Dilini Nakkawita
- Department of Clinical Microbiology, Faculty of Medicine, General Sir John Kotelawala Defence University, Dehiwala-Mount Lavinia 10390, Sri Lanka;
| | - Michele Bolscher
- Tygerberg Academic Hospital and Faculty of Health Sciences, Stellenbosch University, Cape Town 7505, South Africa; (S.M.); (M.B.)
| | - Eva M. Krockow
- Department of Neuroscience, Psychology and Behaviour, University of Leicester, Leicester LE1 7RH, UK; (A.M.C.); (E.M.K.)
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