Views and experiences with regard to antibiotic use of hospitalized patients in five European countries: a qualitative descriptive study

Empowered hospitalized patients are involved in shared decision making on antibiotic therapy: a quantitative analysis

BACKGROUND

Half of hospitalized patients receive antibiotics, but they are rarely involved in shared decision making (SDM) on antibiotic therapy. We sought to understand the association between patient empowerment and their involvement in SDM on antibiotic therapy.

METHODS

From March 2021 to April 2022, we conducted a cross-sectional survey on hospitalized patients receiving antibiotic therapy for ≥1 day in a 1600-bed adult general hospital in Singapore. The questionnaire included seven items (five-point Likert scale) on involvement in SDM from SDM-Q-9 and 10 items (four-point Likert scale) on patient empowerment from HCEQ-10. A multi-variable logistic regression model was constructed to assess for independent associations between the three constructs of patient empowerment and involvement in SDM on antibiotic therapy.

RESULTS

Of 636 hospitalized patients, mean age was 57.6 (SD 15.5) years, 61% were males and 37% had tertiary-level education. The majority (90%) were aware that they were on antibiotic therapy, but only 11% of them knew the name of the antibiotic given. After adjusting for age, gender, ethnicity, educational level, and duration of hospital stay, patients with a high-level of involvement in decisions (adjusted odds ratio (AOR) 3.63, 95% confidence interval (CI) 2.19-6.01), interactions with healthcare professionals (AOR 1.77, 95% CI 1.03-3.02), and degree of control over their hospital care (AOR 1.90, 95% CI 1.15-3.12) were more likely to have a high-level of involvement in SDM on antibiotic therapy.

CONCLUSIONS

Empowering hospitalized patients with involvement in decisions, interactions with healthcare professionals, and control of their hospital care can increase their participation in SDM on antibiotic therapy in hospitals.

Patient and public understanding of antimicrobial resistance: a systematic review and meta-ethnography

Objectives

To further develop an understanding of laypeople's (adult patients and public) beliefs and attitudes toward antimicrobial resistance (AMR) by developing a conceptual model derived from identifying and synthesizing primary qualitative research.

Methods

A systematic search of 12 electronic databases, including CINAHL, MEDLINE, PsycINFO, PubMed and Web of Science to identify qualitative primary studies exploring patient and public understanding of AMR published between 2012 and 2022. Included studies were quality appraised and synthesized using Noblit and Hare's meta-ethnographic approach and reported using eMERGe guidance.

Results

Thirteen papers reporting 12 qualitative studies were synthesized. Studies reported data from 466 participants aged 18-90 years. Five themes were identified from these original studies: the responsible patient; when words become meaningless; patient-prescriber relationship; past experience drives antibiotic use; and reframing public perception. These themes supported the development of a conceptual model that illustrates the tension between two different assumptions, that is, how can antibiotics be used for the collective good whilst balancing the immediate needs of individual patients.

Conclusions

Findings suggest that AMR is a distinct ethical issue and should not be viewed purely as a prescribing problem. The meta-ethnography-generated conceptual model illustrates many factors affecting the public's perception of AMR. These include laypeople's own knowledge, beliefs and attitudes around antibiotic use, the relationship with the healthcare provider and the wider context, including the overwhelming influence of the media and public health campaigns. Future research is needed to explore effective health messaging strategies to increase laypeople's baseline awareness of AMR as a public threat.

Hospitalised patients as stewards of their own antibiotic therapy: a qualitative analysis informing the strategic design of interventions to encourage shared decision-making in tertiary hospital settings in Singapore

Background

Shared decision-making (SDM) on antibiotic therapy may improve antibiotic use in tertiary hospitals, but hospitalised patients are apprehensive about being involved in it. Understanding the facilitators and barriers to SDM can inform the design and implementation of interventions to empower these patients to engage in SDM on their antibiotic therapies.

Methods

We conducted qualitative interviews with 23 adult patients purposively sampled with maximum variation from the three largest tertiary-care hospitals in Singapore (April 2019─October 2020). Thematic analysis was conducted using the Theoretical Domains Framework and Capability, Opportunity, Motivation, Behaviour (COM-B) model to identify areas for intervention.

Results

Hospitalised patients lacked comprehensive knowledge of their antibiotic therapies and the majority did not have the skills to actively query their doctors about them. There was a lack of opportunities to meet and interact with doctors, and patients were less motivated to engage in SDM if they had a self-perceived paternalistic relationship with doctors, trusted their doctors to provide the best treatment, and had self-perceived poor knowledge to engage in SDM. To empower these patients, they should first be educated with antibiotic knowledge. Highlighting potential side effects of antibiotics could motivate them to ask questions about their antibiotic therapies. Environment restructuring, as facilitated by nurses and visual cues to nudge conversations, could create opportunities for interactions and motivating patients into SDM on their antibiotic therapies.

Conclusion

Education and environmental restructuring should be explored to empower hospitalised patients to engage in SDM on their antibiotic therapies.

Decisions on antibiotic prescribing for suspected urinary tract infections in frail older adults: a qualitative study in four European countries

BACKGROUND

a suspected urinary tract infection (UTI) is the most common reason to prescribe antibiotics in a frail older patient. Frequently, antibiotics are prescribed unnecessarily. To increase appropriate antibiotic use for UTIs through antibiotic stewardship interventions, we need to thoroughly understand the factors that contribute to these prescribing decisions.

OBJECTIVES

(1) to obtain insight into factors contributing to antibiotic prescribing for suspected UTIs in frail older adults. (2) To develop an overarching model integrating these factors to guide the development of antibiotic stewardship interventions for UTIs in frail older adults.

METHODS

we conducted an exploratory qualitative study with 61 semi-structured interviews in older adult care settings in Poland, the Netherlands, Norway and Sweden. We interviewed physicians, nursing staff, patients and informal caregivers.

RESULTS

participants described a chain of decisions by patients, caregivers and/or nursing staff preceding the ultimate decision to prescribe antibiotics by the physician. We identified five themes of influence: (1) the clinical situation and its complexity within the frail older patient, (2) diagnostic factors, such as asymptomatic bacteriuria, (3) knowledge (gaps) and attitude, (4) communication: interprofessional, and with patients and relatives and (5) context and organisation of care, including factors such as availability of antibiotics (over the counter), antibiotic stewardship efforts and factors concerning out-of-hours care.

CONCLUSIONS

decision-making on suspected UTIs in frail older adults is a complex, multifactorial process. Due to the diverse international setting and stakeholder variety, we were able to provide a comprehensive overview of factors to guide the development of antibiotic stewardship interventions.

Autonomy, power dynamics and antibiotic use in primary healthcare: A qualitative study

Antibiotic resistance is a global health concern. Although numerous strategies have tried to reduce inadequate antibiotic prescribing, antibiotics are still prescribed in 60% of acute lower respiratory tract infections (ALRTIs) cases in Catalonia (Spain). This study aims to explore service users' experiences of ALRTIs, the quality and access to healthcare services, and health education. Selective purposive sampling was carried out, based on a prior definition of participant characteristics. These were sex, age, ethnicity, date of the last ALRTI, number of ALRTIs in the last year, and treatments received. Participants with a previous diagnosis of ALRTIs were recruited from three primary health care centres in Barcelona and one in Tarragona. Twenty-nine interviews were conducted between April and June 2019. A content thematic analysis was performed. Three themes were identified: 1) risk perceptions and help-seeking; 2) treatment preferences and antibiotic use; and 3) relationship dynamics and communication with healthcare professionals. Accounts of service users' sense of autonomy towards their health and power dynamics within the healthcare system were apparent. Supporting service users to become reliable, subjective and agentic experts of their health and bodies could help them to voice their healthcare agendas. Power structures embedded within healthcare, political and economic institutions should be challenged so that healthcare services can be co-developed (with service users) and based on service users' autonomy and horizontal relationships. Special consideration should be paid to the intersection of social vulnerabilities. A concordance approach to prescribing could be key to improve the responsible use of antibiotics and to contribute to the prevention of AMR in primary healthcare. The marketisation of health, and the increased demands of private healthcare in Spain due to the financial pressures on public healthcare as a consequence of the financial crisis of 2008 and the COVID-19 pandemic, are a risk for promoting adequate antibiotic prescribing and use. Trial registration The ISAAC-CAT study has been registered in the NCT registry, ID: NCT03931577.

Patient engagement with antibiotic messaging in secondary care: a qualitative feasibility study of the ‘review and revise’ experience

Background

We aimed to investigate and optimise the acceptability and usefulness of a patient leaflet about antibiotic prescribing decisions made during hospitalisation, and to explore individual patient experiences and preferences regarding the process of antibiotic prescription ‘review and revise’ which is a key strategy to minimise antibiotic overuse in hospitals.

Methods

In this qualitative study, run within the feasibility study of a large, cluster-randomised stepped wedge trial of 36 hospital organisations, a series of semi-structured, think-aloud telephone interviews were conducted and data were analysed using thematic analysis. Fifteen adult patients who had experienced a recent acute medical hospital admission during which they had been prescribed antimicrobials and offered a patient leaflet about antibiotic prescribing were recruited to the study.

Results

Participants reacted positively to the leaflet, reporting that it was both an accessible and important source of information which struck the appropriate balance between informing and reassuring. Participants all valued open communication with clinicians, and were keen to be involved in antibiotic prescribing decisions, with individuals reporting positive experiences regarding antibiotic prescription changes or stopping. Many participants had prior experience or knowledge of antibiotics and resistance, and generally welcomed efforts to reduce antibiotic usage. Overall, there was a feeling that healthcare professionals (HCPs) are trusted experts providing the most appropriate treatment for individual patient conditions.

Conclusions

This study offers novel insights into how patients within secondary care are likely to respond to messages advocating a reduction in the use of antibiotics through the ‘review and revise’ approach. Due to the level of trust that patients place in their care provider, encouraging HCPs within secondary care to engage patients with greater communication and information provision could provide great advantages in the drive to reduce antibiotic use. It may also be beneficial for HCPs to view patient experiences as cumulative events that have the potential to impact future behaviour around antibiotic use. Finally, pre-testing messages about antibiotic prescribing and resistance is vital to dispelling any misconceptions either around effectiveness of treatment for patients, or perceptions of how messages may be received.

Trial registration

Current Controlled Trials ISRCTN12674243 (10 April 2017),

Quality of outpatient parenteral antimicrobial therapy (OPAT) care from the patient's perspective: a qualitative study

OBJECTIVES

Current outpatient parenteral antimicrobial therapy (OPAT) guidelines recommend delivering patient-centred care. However, little is known about what patients define as good quality of OPAT care and what their needs and preferences are.The aim of this qualitative study is to explore the patients' perspective on high-quality care, and to explore what patient-centred care means to adult OPAT patients.

DESIGN AND SETTING

This is an explorative, descriptive study using qualitative methods. We conducted focus group interviews with 16 adult patients (5 female, 11 male) from 3 different hospitals, who received OPAT and 2 individual semistructured interviews with their informal caregivers in the Netherlands. We used purposive sampling to ensure diversity of participants. We used the eight Picker principles of patient-centredness to guide data collection and analysis.

RESULTS

Participants reported several elements considered as important for patient-centred OPAT care, like patient involvement in the decision-making process, a responsible OPAT lead, intensive collaboration between all disciplines involved, information provision and adherence to hygiene guidelines. Two central dimensions emerged as essential constituents of patient-centred OPAT care: freedom and safety. Both are heavily influenced by the behaviours of healthcare professionals and by organisational aspects beyond the direct influence of these professionals.

CONCLUSION

This study provides insights into the needs and preferences of adult patients who receive OPAT care. Future interventions directed at the improvement of patient-centredness of OPAT care should focus on elements that enhance patients' feelings of freedom and safety.