Content and Mechanism of Action of National Antimicrobial Stewardship Interventions on Management of Respiratory Tract Infections in Primary and Community Care

Determining a future policy focus to support antimicrobial stewardship in community pharmacy: A modified Delphi study

Background

Over the past decade, the pharmacy sector's policy, academic and professional spheres have increasingly drawn attention to the opportunities to better leverage the untapped potential of the community pharmacy sector in contributing to global efforts to reduce antimicrobial resistance (AMR). While efforts are in train, progress is slow.

Objective

To draw insights from global experts in the field to identify a broad range of potential future policy directions to support community pharmacists' involvement in antimicrobial stewardship (AMS).

Methods

A modified Delphi technique, comprising two survey rounds to build consensus amongst global community pharmacy sector stakeholders and opinion leaders. In Round 1, participants rated their level of agreement with 28 statements across the three domains of policy design, implementation design, and monitoring and evaluation. Participants were also invited to contribute feedback in Round 1, which was reflected as new statements (n = 10) in Round 2. In Round 2, participants were asked to re-assess Round 1 statements in view of the group consensus and to rate the new statements.

Results

289 participants were invited to participate. 48/289 (17% response rate) completed Round 1, and 25/42 (60% response rate) completed Round 2. Consensus (defined as >70% agreement) was achieved for 79% (n = 30) of the statements across the three domains.

Conclusion

Pharmacy sector experts agreed that acknowledging community pharmacists in AMS national action plans is an important component, signalling a recognition of the sector's contribution to whole-of-nation AMS efforts. Implementation components that achieved consensus reflect the profession's evolution to a professional service driven model, particularly in complementary AMS initiatives including infection prevention and control measures. Context-specific adjustments to support implementing these AMS measures will be required, in addition to striking the appropriate balance to support the pace of increased community pharmacists'involvement in AMS with building whole-of-profession buy-in.

An approach for embedding behavioural science in antimicrobial resistance One Health research

Antimicrobial Resistance (AMR) is a global health emergency that threatens modern medicine and incurs great cost to human health. The World Health Organization as part of a quadripartite joint initiative with the Food and Agriculture Organization of the United Nations, World Organisation for Animal Health, and United Nations Environment Programme, has recently published a One Health Priority Research Agenda for AMR. In this article we present a multidisciplinary approach, proposed by behavioural science experts, One Health experts and AMR experts to support the implementation of the Priority Research Agenda. We review, using specific examples of complex interventions designed to tackle AMR in which behavioural science has been embedded, five main steps: Define - what behaviours are a priority in each context; Diagnose - What are the barriers and enablers to the behaviours prioritised? Design - what interventions exist and what new or enhanced interventions could work to tackle the barriers identified? and, Implement and Evaluate the intervention(s). The approach presented will be useful for funders and researchers who wish to incorporate methods, frameworks and insights from the behavioural sciences into research plans, proposals and protocols in relation to a multisectoral One Health agenda and produce findings that are more relevant to policymakers.

Impact of the COVID-19 pandemic on antimicrobial stewardship support for general practices in England: a qualitative interview study

BACKGROUND

In England, clinical commissioning group (CCG; now replaced by Integrated Care Systems [ICSs]) and primary care network (PCN) professionals support primary care prescribers to optimise antimicrobial stewardship (AMS).

AIM

To explore views and experiences of CCG and PCN staff in supporting AMS, and the impact of COVID-19 on this support.

DESIGN & SETTING

Qualitative interview study in primary care in England.

METHOD

Semi-structured interviews with staff from CCG and PCNs responsible for AMS were conducted at two timepoints via telephone. These were audio-recorded, transcribed, and analysed thematically.

RESULTS

Twenty-seven interviews were conducted with 14 participants (nine CCG, five PCN) in December 2020-January 2021 and February-May 2021. The study found that AMS support was (1) deprioritised in order to keep general practice operational and deliver COVID-19 vaccines; (2) disrupted as social distancing made it harder to build relationships, conduct routine AMS activities, and challenge prescribing decisions; and (3) adapted, with opportunities identified for greater use of technology and changing patient and public perceptions of viruses and self-care. It was also found that resources to support AMS were valued if they were both novel, to counter AMS 'fatigue', and sufficiently familiar to fit with existing and/or future AMS.

CONCLUSION

AMS needs to be reprioritised in general practice in the post-pandemic era and within the new ICSs in England. This should include interventions and strategies that combine novel elements with already familiar strategies to refresh prescribers' motivation and opportunities for AMS. Behaviour change interventions should be aimed at improving the culture and processes for how PCN pharmacists voice concerns about AMS to prescribers in general practice and take advantage of the changed patient and public perceptions of viruses and self-care.

Analysis of music-exposure interventions for impacting prosocial behaviour via behaviour change techniques and mechanisms of action: a rapid review

The aim of the study is to evaluate the interventions examining music exposure’s effects on prosocial behaviour, to identify the behaviour change techniques (BCTs) through which they change it, and to examine the mechanisms of action (MoAs) that mediate the relationship between music exposure and prosocial behaviour. The review identified 15 research articles, comprising 19 relevant studies. The results revealed that, though many of the included studies did not provide enough information to code them adequately, the BCTs “Instruction on how to perform a behaviour”, “Salience of consequences”, “Reduce negative emotions” and “Identification of self as role model” were the most commonly utilized techniques. Additionally, “Emotion” was the most significant MoA in the intervention-behaviour relationship in this context, but too few BCTs were able to be coded to make conclusions about any BCT-MoA relationships.

Factors Influencing the Implementation of Antimicrobial Stewardship in Primary Care: A Narrative Review

Antimicrobial resistance (AMR) is directly driven by inappropriate use of antibiotics. Although the majority of antibiotics (an estimated 80%) are consumed in primary care settings, antimicrobial stewardship (AMS) activities in primary care remain underdeveloped and factors influencing their implementation are poorly understood. This can result in promising stewardship activities having little-to-no real-world impact. With this narrative review, we aim to identify and summarize peer-reviewed literature reporting on (1) the nature and impact of AMS interventions in primary care and (2) the individual and contextual factors influencing their implementation. Reported activities included AMS at different contextual levels (individual, collective and policy). AMS activities being often combined, it is difficult to evaluate them as stand-alone interventions. While some important individual and contextual factors were reported (difficulty to reach physicians leading to a low uptake of interventions, tight workflow of physicians requiring implementation of flexible and brief interventions and AMS as a unique opportunity to strengthen physician-patients relationship), this review identified a paucity of information in the literature about the factors that support or hinder implementation of AMS in primary care settings. In conclusion, identifying multilevel barriers and facilitators for AMS uptake is an essential step to explore before implementing primary care AMS interventions.

Outcomes to evaluate care for adults with acute dental pain and infection: a systematic narrative review

OBJECTIVE

To identify outcomes reported in peer-reviewed literature for evaluating the care of adults with acute dental pain or infection.DesignSystematic narrative review.

SETTING/PARTICIPANTS

Primary research studies published in peer-reviewed literature and reporting care for adults with acute dental pain or infection across healthcare settings. Reports not in English language were excluded.

STUDY SELECTION

Seven databases (CINAHL Plus, Dentistry and Oral Sciences Source, EMBASE, MEDLINE, PsycINFO, Scopus, Web of Science) were searched from inception to December 2020. Risk of bias assessment used the Critical Appraisal Skills Programme checklist for randomised controlled trials and Quality Assessment Tool for Studies of Diverse Design for other study types.

OUTCOMES

Narrative synthesis included all outcomes of care for adults with acute dental pain or infection. Excluded were outcomes about pain management to facilitate treatment, prophylaxis of postsurgical pain/infection or traumatic injuries.

RESULTS

Searches identified 19 438 records, and 27 studies (dating from 1993 to 2020) were selected for inclusion. Across dental, pharmacy, hospital emergency and rural clinic settings, the studies were undertaken in high-income (n=20) and low/middle-income (n=7) countries. Two clinical outcome categories were identified: signs and symptoms of pain/infection and complications following treatment (including adverse drug reactions and reattendance for the same problem). Patient-reported outcomes included satisfaction with the care. Data collection methods included patient diaries, interviews and in-person reviews.

DISCUSSION

A heterogeneous range of study types and qualities were included: one study, published in 1947, was excluded only due to lacking outcome details. Studies from dentistry reported just clinical outcomes; across wider healthcare more outcomes were included.

CONCLUSIONS

A combination of clinical and patient-reported outcomes are recommended to evaluate care for adults with acute dental pain or infection. Further research is recommended to develop core outcomes aligned with the international consensus on oral health outcomes.

PROSPERO REGISTRATION NUMBER

CRD42020210183.

Designing a National Veterinary Prescribing Champion Programme for Welsh Veterinary Practices: The Arwain Vet Cymru Project

Antimicrobial use in agriculture has been identified as an area of focus for reducing overall antimicrobial use and improving stewardship. In this paper, we outline the design of a complex antimicrobial stewardship (AMS) intervention aimed at developing a national Veterinary Prescribing Champion programme for Welsh farm animal veterinary practices. We describe the process by which participants were encouraged to design and deliver bespoke individualised AMS activities at practice level by forging participant “champion” identities and communities of practice through participatory and educational online activities. We describe the key phases identified as important when designing this complex intervention, namely (i) involving key collaborators in government and industry to stimulate project engagement; (ii) grounding the design in the literature, the results of stakeholder engagement, expert panel input, and veterinary clinician feedback to promote contextual relevance and appropriateness; and (iii) taking a theoretical approach to implementing intervention design to foster critical psychological needs for participant motivation and scheme involvement. With recruitment of over 80% of all farm animal practices in Wales to the programme, we also describe demographic data of the participating Welsh Veterinary Prescribing Champions in order to inform recruitment and design of future AMS programmes.

Are We Making the Most of Community Pharmacies? Implementation of Antimicrobial Stewardship Measures in Community Pharmacies: A Narrative Review

Community pharmacists recognize the need to implement antimicrobial stewardship activities in community pharmacies. They are in a unique position to provide triage for common primary care indications and to lower the burden of patients at general practitioners’ offices. However, research shows that, in some areas, dispensing of antimicrobials without valid prescription is still highly prevalent. Regardless of training, every community pharmacist can give his contribution to antimicrobial stewardship. One of the basic elements should be antimicrobial dispensing according to regulations, either prescription only, or according to guidelines where pharmacists have prescribing authority. Patient consultation supported with educational materials, such as leaflets, may reduce patients’ expectations to receive antibiotics for self-limiting infections and reduce pressure on general practitioners to prescribe antibiotics on patients’ demand. Treatment optimization may be achieved in collaboration with the prescribing general practitioners or by providing feedback. At last, pharmacists provided with additional training may be encouraged to provide consultation services to long-term care facilities, to introduce point-of-care testing for infectious diseases in their pharmacies or prescribe antimicrobials for uncomplicated infections. These services are welcomed by patients and communities. Expanding pharmacy services and pharmacists’ prescribing autonomy have shown a positive impact by reducing antibiotics consumption, thus ensuring better compliance with treatment guidelines.

Optimising antimicrobial stewardship interventions in English primary care: a behavioural analysis of qualitative and intervention studies

OBJECTIVE

While various interventions have helped reduce antibiotic prescribing, further gains can be made. This study aimed to identify ways to optimise antimicrobial stewardship (AMS) interventions by assessing the extent to which important influences on antibiotic prescribing are addressed (or not) by behavioural content of AMS interventions.

SETTINGS

English primary care.

INTERVENTIONS

AMS interventions targeting healthcare professionals' antibiotic prescribing for respiratory tract infections.

METHODS

We conducted two rapid reviews. The first included qualitative studies with healthcare professionals on self-reported influences on antibiotic prescribing. The influences were inductively coded and categorised using the Theoretical Domains Framework (TDF). Prespecified criteria were used to identify key TDF domains. The second review included studies of AMS interventions. Data on effectiveness were extracted. Components of effective interventions were extracted and coded using the TDF, Behaviour Change Wheel and Behaviour Change Techniques (BCTs) taxonomy. Using prespecified matrices, we assessed the extent to which BCTs and intervention functions addressed the key TDF domains of influences on prescribing.

RESULTS

We identified 13 qualitative studies, 41 types of influences on antibiotic prescribing and 6 key TDF domains of influences: 'beliefs about consequences', 'social influences', 'skills', 'environmental context and resources', 'intentions' and 'emotions'. We identified 17 research-tested AMS interventions; nine of them effective and four nationally implemented. Interventions addressed all six key TDF domains of influences. Four of these six key TDF domains were addressed by 50%-67% BCTs that were theoretically congruent with these domains, whereas TDF domain 'skills' was addressed by 24% of congruent BCTs and 'emotions' by none.

CONCLUSIONS

Further improvement of antibiotic prescribing could be facilitated by: (1) national implementation of effective research-tested AMS interventions (eg, electronic decision support tools, training in interactive use of leaflets, point-of-care testing); (2) targeting important, less-addressed TDF domains (eg, 'skills', 'emotions'); (3) using relevant, under-used BCTs to target key TDF domains (eg, 'forming/reversing habits', 'reducing negative emotions', 'social support'). These could be incorporated into existing, or developed as new, AMS interventions.