Failure to implement hospital antimicrobial prescribing guidelines: a comparison of two UK academic centres

Instruments used to measure knowledge and attitudes of healthcare professionals towards antibiotic use for the treatment of urinary tract infections: A systematic review

Background

Urinary tract infections (UTIs) are the second most common condition (after upper respiratory tract infections) for which adults receive antibiotics, and this prevalence may contribute to antibiotic resistance. Knowledge and attitudes have been identified as potential determinants of antibiotic prescribing behaviour among healthcare professionals in the treatment and management of UTIs. An instrument that captures prescribers’ baseline knowledge of and attitudes towards antibiotic prescribing for UTIs could inform interventions to enhance prescribing. The current systematic review evaluates the psychometric properties of instruments already available and describes the theoretical constructs they measure.

Methods

Five electronic databases were searched for published studies and instruments. The Consensus-based Standards for the selection of health status Measurement Instruments checklist was used to assess the psychometric quality reporting of the instruments. The items included in each instrument were mapped onto the theoretical constructs underlying knowledge and attitudes using a mixed-theoretical model developed for this study.

Results

Fourteen studies met the review inclusion criteria. All instruments were available for review. None of the instruments had all the psychometric properties evaluated. Most of the instruments sought to identify knowledge and/or attitude factors influencing antibiotic prescribing for UTIs rather than to measure/assess knowledge and attitudes.

Conclusions

Few instruments for the assessment of knowledge and attitudes of healthcare professionals towards antibiotic use and UTI treatment are available. None of the instruments underwent the full development process to ensure that all psychometric properties were met. Furthermore, none of the instruments assessed all domains of knowledge and attitudes. Therefore, the ability of the instruments to provide a robust measurement of knowledge and attitudes is doubtful. There is a need for an instrument that fully and accurately measures the constructs of knowledge and attitude of healthcare professionals in the treatment of UTIs.

Issues beyond resistance: inadequate antibiotic therapy and bacterial hypervirulence

The administration of antibiotics while critical for treatment, can be accompanied by potentially severe complications. These include toxicities associated with the drugs themselves, the selection of resistant organisms and depletion of endogenous host microbiota. In addition, antibiotics may be associated with less well-recognized complications arising through changes in the pathogens themselves. Growing evidence suggests that organisms exposed to antibiotics can respond by altering the expression of toxins, invasins and adhesins, as well as biofilm, resistance and persistence factors. The clinical significance of these changes continues to be explored; however, it is possible that treatment with antibiotics may inadvertently precipitate a worsening of the clinical course of disease. Efforts are needed to adjust or augment antibiotic therapy to prevent the transition of pathogens to hypervirulent states. Better understanding the role of antibiotic-microbe interactions and how these can influence disease course is critical given the implications on prescription guidelines and antimicrobial stewardship policies.

Interventions to improve antimicrobial prescribing of doctors in training (IMPACT): a realist review

Background

Interventions to improve the antimicrobial prescribing practices of doctors have been implemented widely to curtail the emergence and spread of antimicrobial resistance, but have been met with varying levels of success.

Objectives

This study aimed to generate an in-depth understanding of how antimicrobial prescribing interventions ‘work’ (or do not work) for doctors in training by taking into account the wider context in which prescribing decisions are enacted.

Design

The review followed a realist approach to evidence synthesis, which uses an interpretive, theory-driven analysis of qualitative, quantitative and mixed-methods data from relevant studies.

Setting

Primary and secondary care.

Participants

Not applicable.

Interventions

Studies related to antimicrobial prescribing for doctors in training.

Main outcome measures

Not applicable.

Data sources

EMBASE (via Ovid), MEDLINE (via Ovid), MEDLINE In-Process & Other Non-Indexed Citations (via Ovid), PsycINFO (via Ovid), Web of Science core collection limited to Science Citation Index Expanded (SCIE) and Conference Proceedings Citation Index – Science (CPCI-S) (via Thomson Reuters), Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, the Health Technology Assessment (HTA) database (all via The Cochrane Library), Applied Social Sciences Index and Abstracts (ASSIA) (via ProQuest), Google Scholar (Google Inc., Mountain View, CA, USA) and expert recommendations.

Review methods

Clearly bounded searches of electronic databases were supplemented by citation tracking and grey literature. Following quality standards for realist reviews, the retrieved articles were systematically screened and iteratively analysed to develop theoretically driven explanations. A programme theory was produced with input from a stakeholder group consisting of practitioners and patient representatives.

Results

A total of 131 articles were included. The overarching programme theory developed from the analysis of these articles explains how and why doctors in training decide to passively comply with or actively follow (1) seniors’ prescribing habits, (2) the way seniors take into account prescribing aids and seek the views of other health professionals and (3) the way seniors negotiate patient expectations. The programme theory also explains what drives willingness or reluctance to ask questions about antimicrobial prescribing or to challenge the decisions made by seniors. The review outlines how these outcomes result from complex inter-relationships between the contexts of practice doctors in training are embedded in (hierarchical relationships, powerful prescribing norms, unclear roles and responsibilities, implicit expectations about knowledge levels and application in practice) and the mechanisms triggered in these contexts (fear of criticism and individual responsibility, reputation management, position in the clinical team and appearing competent). Drawing on these findings, we set out explicit recommendations for optimal tailoring, design and implementation of antimicrobial prescribing interventions targeted at doctors in training.

Limitations

Most articles included in the review discussed hospital-based, rather than primary, care. In cases when few data were available to fully capture all the nuances between context, mechanisms and outcomes, we have been explicit about the strength of our arguments.

Conclusions

This review contributes to our understanding of how antimicrobial prescribing interventions for doctors in training can be better embedded in the hierarchical and interprofessional dynamics of different health-care settings.

Future work

More work is required to understand how interprofessional support for doctors in training can contribute to appropriate prescribing in the context of hierarchical dynamics.

Study registration

This study is registered as PROSPERO CRD42015017802.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Professional practice evaluation of emergency department prescriptions for community-acquired infections in Lebanon

BACKGROUND

Selecting the appropriate antibiotic regimen is extremely important in improving patient outcomes, minimizing antimicrobial resistance, and reducing costs. This study was conducted to evaluate current prescribing practices for empiric antibiotics at the time of admission to the emergency department (ED) and to assess their appropriateness in Lebanon.

METHODS

A retrospective observational study was conducted at three different Lebanese hospitals between June and December 2016. Adult patients who received antibiotics in the ED during the study period were included. The assessment of antibiotic therapy based on adherence to international guidelines, including the choice of antibiotic, dosing, or both, was considered for analysis.

RESULTS

A total of 258 patients who had a single diagnosis of an infectious disease were included. Adherence to international guidelines was noted in only 32.6% of cases; the frequency was highest for skin and soft tissue infections (50.0%), followed by urinary tract infections (40%). Among the different antibiotic classes, the highest percentage of drug incompatibility was for β-lactam prescriptions (70.8%). The percentage of incompatibility with guidelines for administered regimens on the basis of drug selection, dosing, or both was 53.4%, 10.3%, and 36.2%, respectively.

CONCLUSIONS

Inappropriate antibiotic use in the ED is prevalent, and physician adherence to international guidelines for empiric antibiotic prescriptions in the ED remains low. This emphasizes the importance of monitoring the use of antibiotics in the ED, as there is growing concern for antibiotic resistance and healthcare safety.

Social and professional influences on antimicrobial prescribing for doctors-in-training: a realist review

Background

Antimicrobial resistance has led to widespread implementation of interventions for appropriate prescribing. However, such interventions are often adopted without an adequate understanding of the challenges facing doctors-in-training as key prescribers.

Methods

The review followed a realist, theory-driven approach to synthesizing qualitative, quantitative and mixed-methods literature. Consistent with realist review quality standards, articles retrieved from electronic databases were systematically screened and analysed to elicit explanations of antimicrobial prescribing behaviours. These explanations were consolidated into a programme theory drawing on social science and learning theory, and shaped though input from patients and practitioners.

Results

By synthesizing data from 131 articles, the review highlights the complex social and professional dynamics underlying antimicrobial prescribing decisions of doctors-in-training. The analysis shows how doctors-in-training often operate within challenging contexts (hierarchical relationships, powerful prescribing norms, unclear roles and responsibilities, implicit expectations about knowledge levels, uncertainty about application of knowledge in practice) where they prioritize particular responses (fear of criticism and individual responsibility, managing one's reputation and position in the team, appearing competent). These complex dynamics explain how and why doctors-in-training decide to: (i) follow senior clinicians' prescribing habits; (ii) take (or not) into account prescribing aids, advice from other health professionals or patient expectations; and (iii) ask questions or challenge decisions. This increased understanding allows for targeted tailoring, design and implementation of antimicrobial prescribing interventions.

Conclusions

This review contributes to a better understanding of how antimicrobial prescribing interventions for doctors-in-training can be embedded more successfully in the hierarchical and inter-professional dynamics of different healthcare settings.

Bacterial clonal diagnostics as a tool for evidence-based empiric antibiotic selection

Despite the known clonal distribution of antibiotic resistance in many bacteria, empiric (pre-culture) antibiotic selection still relies heavily on species-level cumulative antibiograms, resulting in overuse of broad-spectrum agents and excessive antibiotic/pathogen mismatch. Urinary tract infections (UTIs), which account for a large share of antibiotic use, are caused predominantly by Escherichia coli, a highly clonal pathogen. In an observational clinical cohort study of urgent care patients with suspected UTI, we assessed the potential for E. coli clonal-level antibiograms to improve empiric antibiotic selection. A novel PCR-based clonotyping assay was applied to fresh urine samples to rapidly detect E. coli and the urine strain's clonotype. Based on a database of clonotype-specific antibiograms, the acceptability of various antibiotics for empiric therapy was inferred using a 20%, 10%, and 30% allowed resistance threshold. The test's performance characteristics and possible effects on prescribing were assessed. The rapid test identified E. coli clonotypes directly in patients' urine within 25-35 minutes, with high specificity and sensitivity compared to culture. Antibiotic selection based on a clonotype-specific antibiogram could reduce the relative likelihood of antibiotic/pathogen mismatch by ≥ 60%. Compared to observed prescribing patterns, clonal diagnostics-guided antibiotic selection could safely double the use of trimethoprim/sulfamethoxazole and minimize fluoroquinolone use. In summary, a rapid clonotyping test showed promise for improving empiric antibiotic prescribing for E. coli UTI, including reversing preferential use of fluoroquinolones over trimethoprim/sulfamethoxazole. The clonal diagnostics approach merges epidemiologic surveillance, antimicrobial stewardship, and molecular diagnostics to bring evidence-based medicine directly to the point of care.

Understanding the culture of antimicrobial prescribing in agriculture: a qualitative study of UK pig veterinary surgeons

OBJECTIVES

The use of antimicrobials in food-producing animals has been linked with the emergence of antimicrobial resistance in bacterial populations, with consequences for animal and public health. This study explored the underpinning drivers, motivators and reasoning behind prescribing decisions made by veterinary surgeons working in the UK pig industry.

METHODS

A qualitative interview study was conducted with 21 veterinary surgeons purposively selected from all UK pig veterinary surgeons. Thematic analysis was used to analyse transcripts.

RESULTS

Ensuring optimum pig health and welfare was described as a driver for antimicrobial use by many veterinary surgeons and was considered a professional and moral obligation. Veterinary surgeons also exhibited a strong sense of social responsibility over the need to ensure that antimicrobial use was responsible. A close relationship between management practices, health and economics was evident, with improvements in management commonly identified as being potential routes to reduce antimicrobial usage; however, these were not always considered economically viable. The relationship with clients was identified as being a source of professional stress for practitioners due to pressure from farmers requesting antimicrobial prescriptions, and concern over poor compliance of antimicrobial administration by some farmers.

CONCLUSIONS

The drivers behind prescribing decisions by veterinary surgeons were complex and diverse. A combination of education, improving communication between veterinary surgeons and farmers, and changes in regulations, in farm management and in consumer/retailer demands may all be needed to ensure that antimicrobial prescribing is optimal and to achieve significant reductions in use.

Analysis of knowledge and attitude surveys to identify barriers and enablers of appropriate antimicrobial prescribing in three Australian tertiary hospitals

BACKGROUND

Antimicrobial stewardship programmes aim to optimise use of antibiotics and are now mandatory in all Australian hospitals.

AIM

We aimed to identify barriers to and enablers of appropriate antimicrobial prescribing among hospital doctors.

METHODS

Two paper-based and one web-based surveys were administered at three Australian university teaching hospitals from March 2010 to May 2011. The 18-item questionnaire recorded doctors’ level of experience, their knowledge regarding the use of common antimicrobials and their attitudes regarding antimicrobial prescribing. Local survey modifications allowed inclusion of specific questions on: infections in intensive care unit patients, clinical microbiology and use of local guidelines.

RESULTS

The respondents (n = 272) were comprised of 96 (35%) registrars, 67 (25%)residents, 57 (21%) interns and 47 (17%) consultant hospital doctors. Forty-one per cent were working in a medical specialty. Identified barriers included: gaps in antimicrobial prescribing knowledge (especially among interns), a lack of awareness about which antimicrobials were restricted and a reliance on senior colleagues to make antimicrobial prescribing decisions. Enablers of optimal prescribing included: an acknowledgement of the need for assistance in prescribing and reported readiness to consult national prescribing guidelines. These results were used to help guide and prioritise interventions to improve prescribing practices.

CONCLUSION

A transferable knowledge and attitudes survey tool can be used to highlight barriers and facilitators to optimal hospital antimicrobial prescribing in order to inform tailored antimicrobial stewardship interventions.

Effect of a stewardship intervention on adherence to uncomplicated cystitis and pyelonephritis guidelines in an emergency department setting

OBJECTIVE

To evaluate adherence to uncomplicated urinary tract infections (UTI) guidelines and UTI diagnostic accuracy in an emergency department (ED) setting before and after implementation of an antimicrobial stewardship intervention.

METHODS

The intervention included implementation of an electronic UTI order set followed by a 2 month period of audit and feedback. For women age 18-65 with a UTI diagnosis seen in the ED with no structural or functional abnormalities of the urinary system, we evaluated adherence to guidelines, antimicrobial use, and diagnostic accuracy at baseline, after implementation of the order set (period 1), and after audit and feedback (period 2).

RESULTS

Adherence to UTI guidelines increased from 44% (baseline) to 68% (period 1) to 82% (period 2) (P≤.015 for each successive period). Prescription of fluoroquinolones for uncomplicated cystitis decreased from 44% (baseline) to 14% (period 1) to 13% (period 2) (P<.001 and P = .7 for each successive period). Unnecessary antibiotic days for the 200 patients evaluated in each period decreased from 250 days to 119 days to 52 days (P<.001 for each successive period). For 40% to 42% of cases diagnosed as UTI by clinicians, the diagnosis was deemed unlikely or rejected with no difference between the baseline and intervention periods.

CONCLUSIONS

A stewardship intervention including an electronic order set and audit and feedback was associated with increased adherence to uncomplicated UTI guidelines and reductions in unnecessary antibiotic therapy and fluoroquinolone therapy for cystitis. Many diagnoses were rejected or deemed unlikely, suggesting a need for studies to improve diagnostic accuracy for UTI.

[Adherence between antibiotic prescriptions and guidelines in an internal medicine ward: an evaluation of professional practices]

INTRODUCTION

This is an evaluation of professional practices (EPP) on antibiotic therapy in an internal medicine ward.

MATERIAL AND METHODS

A 6-month prospective review of antibiotic prescriptions and their comparisons with local and national guidelines (drug, daily dose, administration, and duration) were performed.

RESULTS

Antibiotic therapy on 227 infectious episodes was collected. According to local guidelines, we found 56% of totally respected (lower respiratory tract infections: 38%, urinary tract infections: 88% and skin infections: 73%), 33% of partially respected and 11% of non-appropriate prescriptions. Considering national guidelines for lower respiratory tract infections as references, the results were: totally respected prescriptions 81%, partially respected prescriptions 16%, and non-appropriate prescriptions 3%.

CONCLUSION

This evaluation of the prescriptions allowed setting up long-lasting actions to improve clinical practice. This approach anticipates the procedures of EPP that will be needed for hospital accreditation and highlights the importance of considering several guidelines for the interpretation of the results.

Prescribing patterns and utilization of antimicrobial drugs in a tertiary care teaching hospital of a Caribbean developing country

This study aimed to evaluate the prescribing practices and utilization of antimicrobials in a tertiary care teaching hospital of a Caribbean developing country. A prospective observational cohort study was undertaken for a period of 12 weeks in the general wards and the intensive care unit (ICU) of the hospital. Demographic data, diagnoses on admission, antimicrobials prescribed, dosage and duration, route of administration, leukocyte count and microbiological culture and sensitivity reports were recorded. Hospital length of stay and final outcome were recorded. The usage was determined in terms of prescribed daily dose and the total costs of antimicrobials were calculated. Of 889 patients admitted, 335 (37.7%) received 22 different antimicrobial drugs. Overall, 67% of the prescriptions adhered to the hospital protocol. Median length of stay in the hospital was 7 days. Skin and soft tissue infections were the most common diagnoses for which antimicrobials were prescribed. Amoxicillin-clavulanate was the most common (32%) antimicrobial used. Eighty-nine percent of the antimicrobials were given through the intravenous route. Sixty percent of the patients received two antimicrobials, 26% received three, and 14% of patients were prescribed four or more antimicrobials during their stay at the hospital. There was significantly higher inappropriate choice of antimicrobials in ICU when compared with general wards (Mantel-Haenszel Odds Ratio 3.3; 95% Confidence Intervals 1.4, 7.7). Prescribing patterns did not strictly adhere to the hospital antimicrobial protocol. There is a need for monitoring and control of antimicrobial prescription.

[Adverse events to antibiotics in inpatients of a university hospital]

OBJECTIVE

Antibiotics are the most common drugs causing adverse events and they lead to problems to patients and additional costs of the health system. The aim of the study was to evaluate the occurrence of adverse events to antibiotics in inpatients of a hospital.

METHODS

An extensive drug monitoring was conducted in adult inpatients taking antibiotics in the city of Maringá, Southern Brazil, from September 2002 to February 2003. Variables related to medications used, especially those related to antibiotic use and adverse events, were studied. Based on criteria for adequate antibiotic use, the observed events were classified as adverse events, medication errors and near-misses. For the analysis of causality between drug administration and event occurrence Naranjo algorithm was used.

RESULTS

A total of 87 patients were studied and 91 adverse events were identified: three (3.3%) adverse drug reactions; seven (7.7%) medication errors; and 81 (89.0%) medication near-misses. Adverse drug reactions were related to the use of quinolones and likely according to Naranjo algorithm. The seven medication errors were associated to four inadequately prescribed doses and three drug interactions.

CONCLUSIONS

The study results indicate that an inadequate knowledge on antibiotics or lack of information about the patient at the time of prescription were the major factors involved in the occurrence of adverse events.

The missing care bundle: antibiotic prescribing in hospitals

The care bundle involves grouping together key elements of care for procedures and the management of specific diagnoses in order to provide a systematic method to improve and monitor the delivery of clinical care processes. In short, care bundles aim to ensure that all patients consistently receive the best care or treatment, all of the time. This approach has been successfully applied to the management of various conditions, particularly in the critical care setting. The Institute for Healthcare Improvement's '100K lives campaign' consisted of six care bundles, three of which have addressed preventing hospital-acquired infection. The UK Department of Health's delivery programme to reduce healthcare-associated infections (HCAIs), including methicillin-resistant Staphylococcus aureus (MRSA), includes six 'high-impact interventions', which are care bundles to reduce HCAIs. However, we suggest that one key intervention is missing, and consider this intervention will be increasingly important if hospitals are to address the rising incidence of Clostridium difficile, to tackle antibiotic resistance and to improve patient care. The missing intervention addresses the process of antibiotic prescribing. We propose that the time is right to consider the application of the care bundle approach to improve the prescribing of antibiotics, both for treatment and prophylaxis.