Pharmacist participation in antimicrobial stewardship in Australian and French hospitals: a cross-sectional nationwide survey

Evaluation of the perspective of pharmacists on antimicrobial stewardship and the barriers to its consolidation in hospitals: a cross-sectional study

Antimicrobial Stewardship Programs (ASPs) are associated with positive outcomes, but seem to be consolidated in few hospitals. This study aimed to evaluate ASPs in Brazilian hospitals and the barriers to their consolidation from the pharmacists' perspective. This is a cross-sectional study. Data were collected through an online questionnaire applied to hospital pharmacists. Data analysis was performed by descriptive statistics and Spearman's ordinal correlation test. A total of 83 pharmacists participated in the study and 45.8% stated that the hospital in which they worked had an ASP. The ASPs were predominantly implemented in public hospitals, with a greater number of beds in the intensive care unit and beds in general. The main barriers to the consolidation of ASPs were: reduced number of pharmacists, time allocated to other demands of the pharmacy, the ineffectiveness of the communication process with doctors, and lack of access to reliable information about antimicrobials in the hospital. Pharmacists that work in hospitals where ASPs were implemented were more confident (p = 0.000) and with a better perception of the barriers that prevent their consolidation (p = 0.003. The ASP was commonly adopted in public hospitals with a greater number of beds. The main obstacles to consolidation were infrastructure, economic, and educational resources.

Determinants of pharmacists' confidence to participate in antimicrobial stewardship: A confirmatory factor analysis

AIM

Pharmacists are essential members of hospital antimicrobial stewardship (AMS) teams. A lack of self-perceived confidence can limit pharmacists' involvement and contributions. Pharmacists working in AMS have reported a lack of confidence. There is currently a lack of validated measures to assess pharmacists' self-perceived confidence when working in AMS and contributors to this confidence. This study aimed to identify variables contributing to pharmacist self-perceived confidence and validate an AMS hospital pharmacist survey tool using confirmatory factor analysis (CFA).

METHODS

Responses from a survey of Australian and French hospital pharmacists were used to undertake CFA and path analysis on factors related to pharmacists' self-perceived confidence. It was hypothesized that pharmacists' self-perceived confidence would be impacted by time working in AMS, perceived importance of AMS programmes, perceived barriers to participating in AMS and current participation.

RESULTS

CFA demonstrated a good model fit between the factors. Items included in the model loaded well to their respective factors with acceptable reliability. Path analysis demonstrated that time working in AMS had a significant impact on pharmacists' self-perceived confidence, while perceived barriers had a negatively significant relationship. Pharmacy participation in AMS and perceived importance of AMS programmes had a non-significant impact.

CONCLUSION

Findings demonstrated that the survey tool showed good validity and identified factors that can impact pharmacists' self-perceived confidence when working in hospital AMS programmes. Having a validated survey tool can identify factors that can reduce pharmacists' self-perceived confidence. Strategies can then be developed to address these factors and subsequently improve pharmacists' self-perceived confidence.

Knowledge, Perception, and Self-Confidence of Antibiotic Resistance, Appropriate Antibiotic Therapy, and Antibiotic Stewardship Among Undergraduate Pharmacy Students in Sudan

Background

Adequate training in infectious diseases and antibiotic resistance is crucial for pharmacy students to participate in antibiotic stewardship programs and understand microbiology careers.

Aim

The study was carried out to assess the knowledge and self-reported confidence in antibiotic resistance, antibiotic therapy, and antimicrobial stewardship (AMS) among final-year undergraduate pharmacy students in Sudan.

Methods

A cross-sectional study was conducted in three universities using a 57-item online questionnaire between April and May 2022.

Results

A total of 109 students (response rate 36%) participated and showed average knowledge scores of 5.6±1.7 (out of 10.0) for antibiotic resistance, 4.9±2.0 (out of 5.0) for appropriate antibiotic therapy, and 3.1±1.4 (out of 5.0) for AMS. No significant differences were observed among schools. Some students reported poor knowledge about antibiotic therapy and the consequences of resistance. One-third of students lacked confidence in interpreting microbiological results. Knowledge of antibiotic resistance among students' practice area after graduation was higher (p=0.017) and those interested in ID careers (5.8 vs 4.8) (p=0.037). Male students (5.6 vs 4.5) and those interested in ID careers (4.3 vs 3.4) (p<0.001) had higher scores of appropriate antibiotic therapy. Students attended antibiotic resistance courses (51.5 vs 45.2), and those interested in ID significantly had higher self-confidence (55.3 vs 45.8) (p=0.008).

Conclusion

Pharmacy students in Sudan have substantial knowledge of AMS and antibiotic resistance with poor knowledge of antibiotic therapy. Adequate training about infectious diseases and related topics is recommended to improve pharmacy students' understanding of microbiological findings, other competencies, and skills to incorporate in antimicrobial stewardship.

Public hospital pharmacists' knowledge, attitudes, and practices for antibiotic stewardship implementation in Limpopo Province, South Africa

BACKGROUND

Hospital pharmacists are important in antibiotic stewardship programs (ASP), a global strategy to combat antibiotic resistance (ABR). South African public hospitals have limited ASP implementation. This study describes Limpopo Provincial Hospital pharmacists' knowledge, attitudes, and practice toward ASP implementation.

METHOD

A questionnaire to explore pharmacists' knowledge, attitudes and practices regarding ASP implementation comprised 43 questions hosted online. A link was sent by invitation e-mail to eligible respondents in November 2021. Five questions on respondents' demographics, 15 questions on ASP knowledge, 10 Likert scale questions on attitude, and 13 on ASP practices were included. Mean (standard deviation (SD)) knowledge and attitude scores and a median (interquartile range (IQR)) practice score was calculated. Associations between categorical variables were assessed using chi-square/Fisher's exact analysis (p < 0.05), with Cramér's V as effect size.

RESULTS

The survey yielded 35 responses (13.1%). Twenty (57.1%) respondents were female. Seventeen (48.6%) respondents were between the ages of 31 and 40 years. The mean knowledge score of respondents was 9.8 (2.6) (N = 34), with knowledge gaps on One Health and socioeconomic determinates of ABR. Ten (29.6%) respondents thought One Health discouraged multi-sector collaboration, and nineteen (55.9%) respondents thought ASP was the only strategic response to ABR. Sixteen (47.1%) respondents did not know that poor access to clean water accelerates ABR and seventeen (50.0%) did not know that poverty could be a determinant for antibiotic use. The mean respondent attitude score was 8.0 (1.7) (N = 28). Twenty-seven (96.4%) respondents agreed that ASP was necessary and agreed to participate in ASP respectively. All 28 (100.0%) respondents agreed to lead an ASP. The median (IQR) respondents' practice score was - 2.0 (IQR: -6.0-5.8) (N = 16). Respondents were inconsistently (never, sometimes, every time) participating in multi-disciplinary forums (6/16, 37.5%) and expressed a desire for training (11/13, 84.6%) on ASP through in-service (7/27, 25.9%). Respondents thought ASP training should include medical officers (12/29, 41.4%) and nurses (9/29, 31.8%). Knowledge score was associated with gender (p = 0.048; V = 0.416) and attitude score (p = 0.013; V = 0.556).

CONCLUSION

Our study found pharmacists had good knowledge and a positive attitude toward ASP implementation but poor ASP practices. A multi-disciplinary in-service training could address identified knowledge and practice gaps.

Benefits of pharmacist intervention in the critical care patients with infectious diseases: A propensity score matching retrospective cohort study

BACKGROUND

The importance of optimising antimicrobial therapy is highlighted in the hospital intensive care unit (ICU) patients. But roles of ICU pharmacists are still in its infancy in China.

OBJECTIVES

This study's objective was to evaluate the values of clinical pharmacist interventions in the antimicrobial stewardship (AMS) on ICU patients with infections.

AIM

The aim of this study was to evaluate the value of clinical pharmacist interventions in the antimicrobial stewardship (AMS) in critically ill patients with infections.

METHODS

From 2017 to 2019, a propensity score matching retrospective cohort research was conducted on critically ill patients with infectious illnesses. The trial was split into groups that received pharmacist assistance and those who did not. Baseline demographics, pharmacist actions, and clinical results were compared between the two groups. Factors influencing mortality were demonstrated using univariate analysis and bivariate logistic regression. The State Administration of Foreign Exchange in China monitored the exchange rate between the RMB and the US dollar and also gathered the charges of the agents as an economic indicator.

RESULTS

Out of the 1523 patients who were evaluated, 102 critically ill patients with infectious diseases were included in each group after matching. The top five prescription regimens adjusted were settled by sickness progression, microbiological results, de-escalation, drug withdrawal, and therapeutic drug monitoring suggestions. The pharmacist exposure group's antibiotic use density (AUD) decreased significantly (p = 0.018) compared to the control group, going from 241.91 to 176.64 defined daily doses/100 bed days. Following pharmacist interventions, the AUD proportion for carbapenems dropped from 23.7 to 14.43%, while for tetracyclines, it dropped from 11.5 to 6.26%. In the group exposed to the pharmacist, the median cost of antibiotics decreased significantly from $836.3 to $362.15 per patient stay (p < 0.001), and the median cost of all medications dropped from $2868.18 to $1941.5 per patient stay (p = 0.06). RMB was converted into US dollars according to the current exchange rate. According to univariate analyses, pharmacist interventions did not differ between the groups that survived and died (p = 0.288).

CONCLUSIONS

This study showed that antimicrobial stewardship had a significant financial return on investment without raising the mortality rate.

Nursing experiences in antimicrobial optimisation in the intensive care unit: A convergent analysis of a national survey

BACKGROUND

Recent evidence highlights the need for an interdisciplinary approach to antimicrobial stewardship (AMS). Nursing involvement in optimising antimicrobials in the intensive care unit (ICU) remains understudied.

OBJECTIVE

The objective of this study was to explore nurses' perceptions and experiences of antimicrobial optimisation or stewardship in ICUs in Australia.

METHODS

An anonymous web-based survey was deployed nationally in early 2021 through two ICU nursing networks. Associations between survey responses were analysed descriptively and by using nonparametric tests (with statistical significance established at p ≤ 0.05). Free-text survey responses underwent qualitative thematic analysis. Interpretation and reporting of quantitative and qualitative data were integrated.

RESULTS

A total of 226 ICU nurses completed the survey. The majority (197/226; 87%) responded that lack of education limits engagement in AMS. Only 13% (30/226) reported the presence of AMS education and training for nurses in their ICUs. Only about half (108/226; 48%) of the nurses were confident to question prescribers when they considered that the antimicrobial prescribed was unnecessary, with nurses in senior roles more likely to do so than nurses providing bedside care (p < 0.05). Gaps in education (including unfamiliarity with AMS roles), noninclusive antimicrobial discussions, moral distress, and potential workload burden were seen as potential barriers/challenges to engagement.

CONCLUSION

The multifactorial barriers identified that inhibit nurses from performing AMS tasks could be addressed by strengthening interprofessional education at all levels and by applying practical AMS interventions that are inclusive for nursing participation. A purposeful culture change that fosters psychological safety and collaborative practice is paramount to supporting nurses in these roles.

Provision of Microbiology, Infection Services and Antimicrobial Stewardship in Intensive Care: A Survey across the Critical Care Networks in England and Wales

Infection rounds in Intensive Care Units (ICU) can impact antimicrobial stewardship (AMS). The aim of this survey was to assess the availability of microbiology, infection, AMS services, and antimicrobial prescribing practices in the UK ICUs. An online questionnaire was sent to clinical leads for ICUs in each region listed in the Critical Care Network for the UK. Out of 217 ICUs, 87 deduplicated responses from England and Wales were analyzed. Three-quarters of those who responded had a dedicated microbiologist, and 50% had a dedicated infection control prevention nurse. Infection rounds varied in their frequency, with 10% providing phone advice only. Antibiotic guidance was available in 99% of the units; only 8% of those were ICU-specific. There were variations in the availability of biomarkers & the duration of antibiotics prescribed for pneumonia (community, hospital, or ventilator), urinary, intra-abdominal, and line infections/sepsis. Antibiotic consumption data were not routinely discussed in a multi-disciplinary meeting. The electronic prescription was available in ~60% and local antibiotic surveillance data in only 47% of ICUs. The survey highlights variations in practice and AMS services and may offer the opportunity to further collaborations and share learnings to support the safe use of antimicrobials in the ICU.

Cross-Sectional Survey on the Current Role of Clinical Pharmacists among Antimicrobial Stewardship Programmes in Catalonia: Much Ado about Nothing

BACKGROUND

Antimicrobial resistance killed 1.27 million people in 2019, so urgent actions are desperately needed. Antimicrobial stewardship programmes (ASPs) are essential to optimize antimicrobial use. The objective was to acknowledge the current role of clinical pharmacists engaged in ASP activities in Catalonia.

METHODS

This was a cross-sectional survey shared through the Catalan Infection Control Programme (VINCat). The survey consisted of four sections and was sent by e-mail.

RESULTS

A total of 69.0% of the centres answered. Pharmacists dedicated a median of 5.0 h per week (2.1 h/week/100 acute care beds), representing 0.15 full time equivalents. The ASP lacked information technology (IT) support, as only 16.3% of centres automatically calculated defined daily doses and days of therapy. Those with less than 15% of their time available for ASPs conducted fewer clinical activities, especially prospective audits and feedback. Those without official infectious diseases training also performed fewer clinical activities, but training was less determinant than IT support or time. Pharmacists performed interventions mostly through annotation in the medical records.

CONCLUSIONS

Clinical pharmacists from Catalonia dedicated to ASPs present an important lack of time and IT support to perform clinical activities. Pharmacists should also improve their clinical skills and try to conduct clinical advice to prescribers, either by phone or face-to-face.

Development of an international survey tool to measure confidence and current antimicrobial stewardship practices of hospital pharmacists

BACKGROUND

Pharmacists are identified as key members of hospital antimicrobial stewardship (AMS) teams in international guidelines. Developing an international standardized tool to measure hospital pharmacists' confidence and practices of AMS will encourage knowledge sharing and better networking between hospital pharmacists internationally.

OBJECTIVES

To develop a survey tool that can be used internationally to assess pharmacists' knowledge, confidence, perceived barriers and current AMS practices.

METHODS

A project team was formed to refine the survey tool that was initially used in a previous survey study. Following revision by the project team, a revised survey tool was sent to the ESCMID Study Group for Antimicrobial Stewardship (ESGAP). Feedback from the ESGAP members was considered by the project team to finalize the survey tool.

RESULTS

A total of 88 changes were made to the survey tool after revision by the project team. A total of 43/216 (19.9%) of ESGAP members provided feedback on the survey tool, which led to a further 19 revisions. ESGAP members were agreeable to the questions in the survey tool, with >50% agreeing that each question was suitable. The final survey tool consisted of 42 questions, reduced from 72 questions in the original survey.

CONCLUSIONS

An international survey tool to measure hospital pharmacists' confidence and practices of AMS was developed. This tool will help the wider hospital pharmacy community in conducting local studies on current AMS practices and to identify areas where further support is needed. Use of a standardized survey tool will also allow individual regions/countries to compare their data with other countries to identify potential quality improvement programmes.

Pharmacist-led antimicrobial stewardship programme in a small hospital without infectious diseases physicians

Pharmacists may be tasked to lead antibiotic stewardship programmes (ASP) implementation in small hospitals in absence of infectious diseases (ID) physicians. The objectives are to evaluate the effectiveness of a pharmacist-led ASP in a hospital without ID physician support, with special focus on indicators of the hospital use of antimicrobial agents based on consumption and asess the potential clinical and economic impact of pharmacist interventions (PIs) through the CLEO tool. A prospective quasi-experimental study to implement an ASP in a 194-bed hospital. We evaluated changes in antimicrobial use measured as mean defined daily doses per 1000 patient-days (AUD) for intervention versus preintervention period. A total of 847 antimicrobial PIs were proposed, being 88.3% accepted. Discontinuation due to excessive duration was the most frequently performed PI (23.4%). Most of PIs was classified as major or moderate clinical impact, 41.7% and 37.8% respectively. The global consumption of antimicrobial was reduced from 907.1 to 693.8 AUD, with a signifcant drop in carbapenems and quinolones. Direct expenditure of antibiotics decreased significantly. Pharmacist-led ASP has being effective in reducing consumption of antibiotics. In the absence of ID physician´s support and oversight, pharmacists could lead the improvement of the use of antimicrobials.

Acceptance Factors for In-Hospital Pharmacist Interventions in Daily Practice: A Retrospective Study

Introduction: Performing pharmacist interventions (PIs) during the medication review helps to improve the quality of care. The acceptance by the physician of these PIs is a good indicator of the quality of this clinical pharmacy activity. The objective of this study was to determine, in the Amiens-Picardie teaching hospital (France), factors of acceptance in a variable environment of activity (central pharmacy, in the care units, computer assisted). Methods: All PIs transcribed by pharmacists on the Act-IP© site between November 2018 and April 2019 were analyzed using a complementary search in patient records. The environment, type, and clinical impact on patient health of each PI was collected. Linear mixed-effects models with a random pharmacist intercept were used to investigate the relationship between PI modalities and their chance of being accepted. Results: A total of 3,100 PIs were traced, of which 2,930 had been followed over time. Of these, 2,930 PIs, 1,504 (51.3%) were performed by a postgraduate pharmacist and 1,426 (48.7%) by a pharmacy resident, 1,623 (55.4%) were performed by verbal exchange, 455 (15.5%) by telephone, 846 (28.9%) by computer software, and 6 (0.2%) by paper. The clinical impact on patient health was major for 976 PIs (33.3%) and vital for 26 PIs (0.9%). According to the Anatomical Therapeutic Chemical Classification (ATC), they were mainly related to anti-infectives (30.3%), the nervous system (18.7%), and blood and blood-forming organs (17.3%). In total, 2,415 PIs (82.4%) were accepted. According to the multivariate model, a PI was more often accepted when it was transmitted orally rather than by software (+27.7%, 95% CI: +23.2 to +32.1%) and when it was transmitted to a medical resident rather than a postgraduate physician (+4.4%, 95% CI: 1.2-7.6%). In these cases, there was a major rather than a moderate clinical impact on patient health (+4.3%, 95% CI: +1.1-+7.6%). Conclusion: This study highlights the importance of the quality of the exchange with the prescriber and the prioritization of high-risk interventions as key points of medication review to improve rate of pharmacist interventions accepted by physician.

Pharmacists' Perceptions of Handling Antimicrobial Resistance (AMR): A Case Study in Saudi Arabia

Introduction

Saudi Arabia is one of the countries facing the emergence of antimicrobial resistance (AMR). The pharmacist is an important stakeholder in the healthcare system who plays a crucial role in avoiding AMR and implementing antimicrobial stewardship (AMS).

Methods

A cross-sectional design was used in this study. The online questionnaire collected data regarding the enablers that have helped in preparing pharmacists to handle AMR and the barriers faced by pharmacy personnel in handling AMR, as well as the strategies used to overcome the identified barriers.

Results

A total of 109 participants were included in the study. Just under two thirds (62.4%) of participants were female and the majority (70.6%) worked as pharmacists. Just under half (41.7%) had between 6 and 10 years of work experience. Three quarters (74.3%) had antimicrobial stewardship in place and around the same number (73.4%) were involved in handling infectious disease management during the COVID-19 pandemic. Pharmacists have found that preparatory items/tasks, pharmacy college curriculum, pharmacy rotation, years of experience and self-education related to AMR handling to be natural, with a mean of 3.2. The participants found all the barriers - insufficient background, in site education and training, limited time, limited CPD activities, limited educational tools and no free access to relevant clinical journals - to be relevant, with a mean of 4.05. The participants found all the enablers - CPD activities, funded educational programs, allowing time for self-education, accessible educational resources and tools, annual evolution of competencies - to be relevant, with a mean of 4.12.

Conclusion

The study concluded that the barriers preventing the handling of AMR could be overcome through allowing pharmacists more time for self-directed continuous education, providing access to tools and online educational resources, and offering pharmacists funded courses to equip them with the knowledge, skills and competencies needed to handle AMR.

Antibiotic stewardship knowledge and belief differences among healthcare professionals in hospitals: A survey study

BACKGROUND

Collaborative practice in healthcare has been recommended to improve the quality of antimicrobial stewardship interventions, a behavioral change in antimicrobial use. Insufficient knowledge regarding antibiotic resistance, the fear of complications from infections, and how providers perceive antibiotic use and resistance are likely to influence prescribing behavior. This study's objective was to identify the knowledge and belief healthcare professionals' differences about antibiotic stewardship.

METHODS

This cross-sectional survey study of three hospitals in the East Java province, Indonesia utilized a 43-item questionnaire to assess antimicrobial stewardship knowledge and belief. There were 12 knowledge questions (total possible score: 12) and 31 belief questions (total possible score: 155). The Kuder Richardson 20 (KR-20) and Cronbach alpha values of the questionnaire were 0.54 and 0.92, respectively.

RESULTS

Out of the 257 respondents, 19% (48/257) had a low scores of knowledge, and 39% (101/257) had low scores on belief about antibiotic stewardship (101/257). Most midwives had a low scores on knowledge (25/61) and low scores on belief (46/61). Respondents with high scores on belief were 17% (10/59) physicians, 15% (4/27) pharmacists, 8% (5/65) nurses, and 3% (2/61) midwives.

CONCLUSION

Among healthcare professionals, knowledge and belief differences concerning antibiotic stewardship vary widely. These differences will affect their capability, behavior, and contribution to the healthcare team collaboration and performance. Further studies are needed to evaluate the correlation between the level of inter-professional collaboration and the quality of the antibiotic stewardship implementation.

Where to from here? Identifying and prioritising future directions for addressing drug-resistant infection in Australia

BACKGROUND

The Australian National Antimicrobial Resistance Strategy calls for a collaborative effort to change practices that have contributed to the development of drug-resistance and for implementation of new initiatives to reduce antibiotic use.

METHODS

A facilitated workshop was undertaken at the 2019 National Australian Antimicrobial Resistance Forum to explore the complexity of antimicrobial stewardship (AMS) implementation in Australia and prioritise future action. Participants engaged in rotating rounds of discussion using a world café format addressing six topics relating to AMS implementation. Once all tables had discussed all themes the discussion concluded and notes were summarised. The documents were independently openly coded by two researchers to identify elements relating to the implementation of antimicrobial stewardship.

RESULTS

There were 39 participants in the facilitated discussions, including pharmacists, infectious disease physicians, infection prevention nurses, and others. Participants discussed strategies they had found successful, including having a regular presence in clinical areas, adapting messaging and implementation strategies for different disciplines, maintaining positivity, and being patient-focused. Many of the recommendations for the next step involved being patient focussed and outcomesdriven. This involves linking data to practice, using patient stories, using data to celebrate wins and creating incentives.

DISCUSSION

Recommendations from the workshop should be included in priority setting for the implementation of AMS initiatives across Australia.

Antimicrobial Stewardship Programs in Northwest China: A Cross-Sectional Survey of Perceptions, Involvement, and Perceived Barriers Among Hospital Pharmacists

Background: Antimicrobial stewardship (AMS) is a key prevention strategy in addressing the global concern of increasing antimicrobial resistance (AMR). Pharmacists are one of the integral members of AMS hospital teams around the world. Toward reducing AMR, a major strategy in China is to improve the capacity and participation of pharmacists in the AMS framework. However, little is known about how hospital pharmacists perceive their position and participation in AMS work, and the barriers to this work in China, especially in the Northwest region. Methods: Region this work describes a cross-sectional, anonymous, online survey study. Hospital pharmacists from five provinces/autonomous regions in northwest China were invited to participate in June and July 2020. Participants completed the survey by using WeChat, a popular social application in China. We purposefully distributed the questionnaire link and QR code to hospital pharmacists through the hospital antimicrobial resistance surveillance network, hospital antimicrobial consumption surveillance network, provincial and city pharmaceutical associations, and hospital pharmacist WeChat groups. Results: Out of 1032 respondents, 93.1% believed that AMS programs promote the judicial prescribing of antimicrobials, 95.5% strongly agreed that AMS could reduce the widespread use of antimicrobials, and 92.3% believed that AMS could improve medical services. Pharmacists were most likely to be involved in AMS through reviewing prescriptions of antimicrobials, intervening in inappropriate prescriptions, and providing feedback on antimicrobial prescriptions and medical orders. Barriers to participating in AMS included workload (59.5% of respondents), ineffective communication between pharmacists and doctors (57.7%), and inadequate knowledge of AMS (47.0%). Differences in responses were found between the five surveyed provinces. A significant association was found between median involvement scores and gender, age, education, level of superiority, experience, and type of hospital (p < 0.05). Conclusion: Pharmacists perceived that AMS programs are important, but that their involvement in related activities is limited in all provinces. Further studies and strategies should consider how to overcome the identified barriers to optimize the participation of pharmacists in AMS programs.

Exploring the practice, confidence and educational needs of hospital pharmacists in reviewing antimicrobial prescribing: a cross-sectional, nationwide survey

BACKGROUND

Antimicrobial stewardship (AMS) programs are usually limited in resources and scope. Therefore, wider engagement of hospital pharmacists in reviewing antimicrobial orders is necessary to ensure appropriate prescribing. We assessed hospital pharmacists' self-reported practice and confidence in reviewing antimicrobial prescribing, and their knowledge in making AMS interventions.

METHODS

We conducted an Australia-wide, cross-sectional survey in October 2017. A link to the online survey was emailed to hospital pharmacists via the Society of Hospital Pharmacists of Australia. Factors associated with higher knowledge scores were explored using linear regression models.

RESULTS

There were 439 respondents, of whom 272 (61.7%) were from metropolitan public hospitals. Pharmacists were more likely to assess the appropriateness of intravenous, broad-spectrum or restricted antibiotics than narrow-spectrum, oral antibiotics within 24-72 h of prescription; p < 0.001. Fifty percent or fewer respondents were confident in identifying AMS interventions related to dose optimization based on infection-specific factors, bug-drug mismatch, and inappropriate lack of spectra of antimicrobial activity. The median knowledge score (correct answers to knowledge questions) was 6 out of 9 (interquartile range, 5-7); key gaps were noted in antimicrobials' anaerobic spectrum, beta-lactam allergy assessment and dosing in immunocompromised patients. Clinical practice in inpatient areas, registration for 3-5 years and receipt of recent AMS education were associated with higher knowledge scores. More interactive modes of education delivery were preferred over didactic modes; p ≤ 0.01.

CONCLUSION

Gaps in practice, confidence and knowledge among hospital pharmacists were identified that could inform the design of educational strategies to help improve antimicrobial prescribing in Australian hospitals.

Antimicrobial stewardship by Australian community pharmacists: Uptake, collaboration, challenges, and needs

OBJECTIVE

To assess community pharmacists' (CPs') awareness and uptake of evidence-based antimicrobial stewardship (AMS) strategies, attitudes toward collaboration with general practitioners (GPs), and needs to improve AMS practices.

METHODS

A nationwide survey of randomly sampled community pharmacies across Australia was conducted in April-October 2019.

RESULTS

The response rate of CPs was 30.7% (613 of 2000) and 592 participating CPs (96.5%) described the key barriers to and facilitators of improving AMS. CPs (447 of 613, 72.9%) were familiar with AMS but felt that they would require training (468 of 612, 76.5%) and access to AMS practice guidelines (566 of 605, 93.6%). Respondents perceived that AMS programs could reduce the inappropriate use of antimicrobials (409 of 612, 66.8%) and the costs of treating infection (508 of 612, 83.0%). CPs often counseled patients (591 of 609, 97.0%) and reviewed drug interactions or allergies (569 of 607, 93.8%) before dispensing antimicrobials. Respondents less often used the national Therapeutic Guidelines: Antibiotic (274 of 602, 45.5%) or assessed guideline-compliance of prescribed antimicrobials (231 of 609, 37.9%). CPs were less likely to communicate with GPs (254 of 609, 41.8%) when an antimicrobial prescription was believed to be suboptimal and perceived that GPs are not receptive to their intervention regarding the antimicrobial choice (500 of 606, 82.6%) and dosage (416 of 606, 68.6%). Point-of-care tests (114 of 596, 19.1%) and patient information leaflets (149 of 608, 24.5%) were used uncommonly. Most respondents supported policies that could foster GP-pharmacist collaboration (560 of 606, 92.4%), limit accessibility of selected antimicrobials (420 of 604, 74.4%), and reduce repeat-dispensing of antimicrobial prescriptions (448 of 604, 74.2%). CPs faced interpersonal, interactional, structural, and resource-level barriers to collaborate with GPs for practicing AMS.

CONCLUSIONS

CPs are aware of the importance of sensible use of antimicrobials but have had limited training and resources to conduct AMS activities. Improving GPs' receptiveness and system structures for increased GP-CP collaboration seem to be a priority to accelerate CP-led AMS implementation. Further study is required to understand the views of stakeholders about the feasibility of implementing evidence-based GP-CP collaborative AMS approaches.

Prescribers' experience and opinions on antimicrobial stewardship programmes in hospitals: a French nationwide survey

OBJECTIVES

To assess prescribers' experiences and opinions regarding antimicrobial stewardship programme (ASP) activities.

METHODS

A cross-sectional paper-based survey was conducted among prescribers in 27 out of 35 randomly selected large hospitals in France.

RESULTS

All 27 investigated hospitals (20 non-university public, 4 university-affiliated and 3 private hospitals) had an ASP and an appointed antibiotic advisor (AA), with a median of 0.9 full-time equivalents per 1000 acute-care beds (IQR 0-1.4). Of the 1963 distributed questionnaires, 920 were completed (46.9%). Respondents were mainly attending physicians (658/918, 71.7%) and medical specialists (532/868, 61.3%). Prescribers identified two main ASP objectives: to limit the spread of resistance (710/913, 77.8%) and to improve patient care and prognosis (695/913, 76.1%). The presence of an AA constituted a core element of ASP (96.2% agreement between answers of ASP leader and respondents). Respondents acknowledged an AA's usefulness especially on therapeutic issues, i.e. choosing appropriate antibiotic (agreement 84.7%) or adapting treatment (89.6%), but less so on diagnostic issues (31.4%). Very few respondents reported unsolicited counselling and post-prescription controls. Three-quarters of prescribers identified local guidelines (692/918, 75.4%). Prescribers did not approve of measures counteracting their autonomy, i.e. automatic stop orders (agreement 23.4%) or pre-approval by AAs (28.8%). They agreed more with educational interventions (73.0%) and clinical staff meetings (70.0%).

CONCLUSIONS

Prescribers perceived ASP mainly through its 'on-demand' counselling activities. They preferred measures that did not challenge their clinical autonomy. High levels of antibiotic consumption in French hospitals bring into question the effectiveness of such an approach. However, limited ASP staffing and resources may preclude extended activities.

Implementation of antibiotic stewardship programmes in French ICUs in 2018: a nationwide cross-sectional survey

BACKGROUND

Antibiotic stewardship programmes have a pivotal role in ICUs, but the level of implementation of these programmes at the regional or national level is not well known.

OBJECTIVES

The aim of our study was to assess the level of implementation of antibiotic stewardship programmes in French ICUs.

METHODS

We conducted a nationwide cross-sectional survey from January to March 2018 using an online questionnaire sent as an E-mail link to ICU specialists (one questionnaire per ICU).

RESULTS

Overall, 113 out of 206 (55%) ICUs participated. Access to local epidemiology regarding bacterial resistance and antibiotic consumption data was reported in 84% and 65% of ICUs, respectively. Local guidelines for antibiotic use were available in 54% of ICUs. The duration of empirical antibiotic therapy was limited in 46% of cases, following the recommendation of an external expert in 33%. An antibiotic stewardship programme leader was reported at the hospital level by 94% of respondents, being an infectious disease physician in 80%. His/her role in the ICU was mostly to discuss specific cases (50%) and to provide advice on antibiotic prescriptions (26%). Regarding microbiological diagnosis, blood cultures were not processed at night or during weekends in 57%. Molecular biology and MS techniques were available in 62% and 59% of cases, respectively. Therapeutic drug monitoring of β-lactams was available in 46% of cases. Forty-three percent of respondents knew the expression 'antimicrobial/antibiotic stewardship'.

CONCLUSIONS

Antibiotic stewardship programmes are not optimally implemented in French ICUs. Improvement efforts and regular monitoring of the level of implementation are needed.

Mechanisms affecting the implementation of a national antimicrobial stewardship programme; multi-professional perspectives explained using normalisation process theory

BACKGROUND

Antimicrobial stewardship (AMS) describes activities concerned with safe-guarding antibiotics for the future, reducing drivers for the major global public health threat of antimicrobial resistance (AMR), whereby antibiotics are less effective in preventing and treating infections. Appropriate antibiotic prescribing is central to AMS. Whilst previous studies have explored the effectiveness of specific AMS interventions, largely from uni-professional perspectives, our literature search could not find any existing evidence evaluating the processes of implementing an integrated national AMS programme from multi-professional perspectives.

METHODS

This study sought to explain mechanisms affecting the implementation of a national antimicrobial stewardship programme, from multi-professional perspectives. Data collection involved in-depth qualitative telephone interviews with 27 implementation lead clinicians from 14/15 Scottish Health Boards and 15 focus groups with doctors, nurses and clinical pharmacists (n = 72) from five Health Boards, purposively selected for reported prescribing variation. Data was first thematically analysed, barriers and enablers were then categorised, and Normalisation Process Theory (NPT) was used as an interpretive lens to explain mechanisms affecting the implementation process. Analysis addressed the NPT questions 'which group of actors have which problems, in which domains, and what sort of problems impact on the normalisation of AMS into everyday hospital practice'.

RESULTS

Results indicated that major barriers relate to organisational context and resource availability. AMS had coherence for implementation leads and prescribing doctors; less so for consultants and nurses who may not access training. Conflicting priorities made obtaining buy-in from some consultants difficult; limited role perceptions meant few nurses or clinical pharmacists engaged with AMS. Collective individual and team action to implement AMS could be constrained by lack of medical continuity and hierarchical relationships. Reflexive monitoring based on audit results was limited by the capacity of AMS Leads to provide direct feedback to practitioners.

CONCLUSIONS

This study provides original evidence of barriers and enablers to the implementation of a national AMS programme, from multi-professional, multi-organisational perspectives. The use of a robust theoretical framework (NPT) added methodological rigour to the findings. Our results are of international significance to healthcare policy makers and practitioners seeking to strengthen the sustainable implementation of hospital AMS programmes in comparable contexts.

Antibiotic de-escalation on internal medicine services with rounding pharmacists compared to services without

Background Antimicrobial stewardship programs ensure antibiotic therapy is used appropriately and includes de-escalation when clinical status or culture data indicates broad-spectrum agents are no longer needed. Although the impact of infectious diseases clinical pharmacists has been well documented, there is limited research evaluating the impact of adult internal medicine clinical pharmacists on broad-spectrum antibiotic de-escalation while rounding on internal medicine teams. Objective To determine if broad-spectrum antibiotics were de-escalated more regularly and more rapidly in patients on internal medicine services with a rounding pharmacist at the bedside compared to internal medicine services without rounding pharmacists. Setting A single 700 bed academic medical center in the United States of America. Method This was a prospective observational cohort chart review. Main outcome measure The primary endpoint was appropriate broad-spectrum antibiotic de-escalation within 72 h or upon return of culture results. Result A total of 64 patients were included in this study with 39 in the pharmacist group and 25 in the no pharmacist group. De-escalation occurred in 35/39 patients on services with pharmacists and in 13/25 patients on services without pharmacists (p = 0.001). In terms of mean days of broad-spectrum antibiotic therapy, services with rounding pharmacists saw patients on Methicillin-resistant Staphylococcus aureus coverage for an average of 2.12 days of their duration of therapy compared to 2.8 days in those without pharmacists (p = 0.821). Services with rounding pharmacists saw patients on Pseudomonas aeruginosa coverage for 2 days of their length of stay compared to 3 days in those without pharmacists (0.398). Conclusion This data shows that broad-spectrum antibiotics were de-escalated more frequently on medicine services with rounding pharmacists compared to services without pharmacists.

Knowledge and self-confidence of antibiotic resistance, appropriate antibiotic therapy, and antibiotic stewardship among pharmacy undergraduate students in three Asian countries

BACKGROUND AND PURPOSE

Training pharmacy students in infectious diseases (ID) is important to enable them to participate in antibiotic stewardship programs. This study evaluated knowledge and self-confidence regarding antibiotic resistance, appropriate antibiotic therapy, and antibiotic stewardship among final year pharmacy undergraduate students.

METHODS

A cross-sectional electronic survey was conducted at universities in Indonesia, Malaysia, and Pakistan. A 59-item survey was administered between October 2017 and December 2017.

FINDINGS

The survey was completed by 211 students (response rate 77.8%). The mean knowledge score for antibiotic resistance, appropriate antibiotic therapy, and antibiotic stewardship was 5.6 ± 1.5, 4.7 ± 1.8 (maximum scores 10.0) and 3.1 ± 1.4 (maximum score 5.0), respectively. Significant variations were noted among the schools. There was poor awareness about the consequences of antibiotic resistance and cases with no need for an antibiotic. The knowledge of antibiotic resistance was higher among male respondents (6.1 vs. 5.4) and those who had attended antibiotic resistance (5.7 vs. 5.2) and antibiotic therapy (5.8 vs. 4.9) courses (p < 0.05). Students with ID clerkship experience (5.2 vs. 4.5) had significantly higher score for appropriate antibiotic therapy.

CONCLUSIONS

Final year pharmacy undergraduate students in Indonesia, Malaysia, and Pakistan had moderate knowledge of antibiotic resistance and antibiotic stewardship. However, the knowledge of appropriate antibiotic therapy was poor.

Knowledge, Perceptions and Practices of Community Pharmacists Towards Antimicrobial Stewardship: A Systematic Scoping Review

The scope of antimicrobial stewardship (AMS) surveys on community pharmacists (CPs) is uncertain. This study examines the breadth and quality of AMS survey tools measuring the stewardship knowledge, perceptions and practices (KPP) of CPs and analyse survey outcomes. Following PRISMA-ScR checklist and Arksey and O'Malley's methodological framework seven medical databases were searched. Two reviewers independently screened the literatures, assessed quality of surveys and KPP outcomes were analysed and described. Ten surveys were identified that assessed CPs' AMS perceptions (n = 7) and practices (n = 8) but none that assessed AMS knowledge. Three survey tools had been formally validated. Most CPs perceived that AMS improved patient care (median 86.0%, IQR, 83.3-93.5%, n = 6), and reduced inappropriate antibiotic use (84.0%, IQR, 83-85%, n = 2). CPs collaborated with prescribers for infection control (54.7%, IQR 34.8-63.2%, n = 4) and for uncertain antibiotic treatment (77.0%, IQR 55.2-77.8%, n = 5). CPs educated patients (53.0%, IQR, 43.2-67.4%, n = 5) and screened guideline-compliance of antimicrobial prescriptions (47.5%, IQR, 25.2-58.3%, n = 3). Guidelines, training, interactions with prescribers, and reimbursement models were major barriers to CP-led AMS implementation. A limited number of validated survey tools are available to assess AMS perceptions and practices of CPs. AMS survey tools require further development to assess stewardship knowledge, stewardship targets, and implementation by CPs.

Nationwide survey of pharmacists' involvement in antimicrobial stewardship programs in Nigerian tertiary hospitals

OBJECTIVES

To evaluate the activities and barriers to hospital pharmacists' participation in antimicrobial stewardship programs (ASP) in Nigerian tertiary hospitals.

METHODS

A cross-sectional nationwide online survey was conducted over a 6-week period between May and June 2019. Invitation was sent to all the Heads of pharmacy department or pharmacists in charge of infectious diseases (ID) or antimicrobial pharmacists in tertiary hospitals in Nigeria. A validated questionnaire that consist of 24-items was used for data collection.

RESULTS

Forty-five hospitals were invited and 37 completed the survey (response rate, 82.2%). Five (13.5%) hospitals had a formal antimicrobial stewardship (AMS) team, with each of them having pharmacist representation. Regardless of the existence of an AMS team, hospital pharmacists have implemented AMS strategies, including evaluation of the appropriateness of antimicrobial prescriptions (54.1%) and monitoring of antimicrobial consumption (48.6%). The most common barriers to pharmacists' involvement in ASP were lack of training in AMS and ID (51.4%), lack of pharmacists with ID specialisation (40.5%) and lack of support from hospital administrators (37.8%). The majority of the pharmacists recommended training in AMS and ID (100%), participation on ward rounds (89.2%) and employment of more pharmacists (73%) as strategies to improve pharmacists' participation in ASP.

CONCLUSIONS

Hospital pharmacists are actively involved in AMS activities despite the lack of established AMS teams in most tertiary hospitals in Nigeria. However, lack of training and personnel were major barriers to pharmacist's involvement in ASP.

Nationwide survey of hospital antibiotic stewardship programs in France

OBJECTIVE

We aimed to evaluate the current state of antibiotic stewardship (ABS) in French public and private acute care hospitals.

METHODS

We conducted a cross-sectional online questionnaire survey. The selection of participating hospitals was performed through a stratified random sampling procedure among all French public and private hospitals with acute care beds.

RESULTS

97/215 (45%) hospitals participated. A formal ABS program was implemented in 84% (80/95) of hospitals. A person officially in charge of this program (i.e., ABS program leader) was present in almost all participating hospitals (99%, 95/96) and s/he coordinated a multidisciplinary ABS team in 42% (40/96) of cases. The median time spent on ABS activities was 1.7, 1.6, and 0.8hours/week/100 acute care beds for infectious disease (ID) specialists, pharmacists, and microbiologists respectively; 27% (7/26) of ID specialists/other clinicians, 58% (15/26) of pharmacists, and 80% (16/20) of microbiologists received no salary support for the stewardship activities conducted as part of the team. Local guidelines (94%, 88/94), electronic medical records (85%, 80/94), and an antibiotic restriction policy (92%, 82/89) were implemented in almost all hospitals. Reports on antibiotic consumption and local resistance rates were available in 100% (91/91) and 84% (76/91) of hospitals, respectively.

CONCLUSION

Despite the existence of national requirements, hospital ABS programs are not fully implemented in France, mainly because of inadequate institutional support and funding.

Validation and implementation of a national survey to assess antimicrobial stewardship awareness, practices and perceptions amongst community pharmacists in Australia

OBJECTIVES

Antimicrobial stewardship (AMS) programmes are well established in hospitals, yet such programmes have not been widely implemented in the community. Understanding current practices and perceptions of community pharmacists about AMS may provide insights into the implementation of AMS in community pharmacies. The aims of this study were to validate a questionnaire to measure community pharmacists' perceptions of AMS and to explore barriers and facilitators to their involvement in community-based AMS initiatives.

METHODS

A 44-item survey questionnaire comprising sections on demographics, AMS practices and perceptions of community pharmacists, and barriers and facilitators to AMS was hosted online. Community pharmacists were recruited through social media pages of community pharmacist groups across Australia. Cronbach's alpha and exploratory factor analysis were used to measure the reliability and validity of the survey tool, respectively.

RESULTS

A total of 330 community pharmacists started the survey, with 255 of them completing at least one question. Pharmacists were more likely to intervene with general practitioners (GPs) (≥80% of the time) for allergies, dosing and drug interactions and were less likely to intervene if they felt the choice of antibiotic was inappropriate (45%). Major barriers limiting pharmacists' participation in AMS were lack of access both to patient data (82.6%) and to a standard guideline to implement AMS programmes (72.1%). Almost all pharmacists (98%) reported that better collaboration with GPs would improve their participation in AMS initiatives.

CONCLUSION

Future studies utilising the knowledge gained from this study may provide a framework for AMS in community pharmacy settings.

Pharmacists' role in antimicrobial stewardship and relationship with antibiotic consumption in hospitals: An observational multicentre study

OBJECTIVES

Antimicrobial stewardship (AMS) teams around the world include pharmacists; however, their impact is relatively unknown. This study aimed to explore the relationship between pharmacists' actions and antibiotic consumption.

METHODS

Hospital pharmacists involved in the French antibiotic consumption surveillance network (ATB-Raisin) were invited to participate in a retrospective observational multicentre study. Collected data were: the previous year's (2016) antibiotic consumption expressed in daily defined dose per 1000 patient-days; AMS measures, including pharmacist-specific actions; and use of a computerised prescription order entry (CPOE) system. Associations between antibiotic consumption and AMS measures were assessed by linear regression, after adjustment for hospital activities.

RESULTS

Annual data for 2016 from 77 hospitals (7260000 bed-days in 24000 beds) were analysed. Pharmacists were involved in AMS programs in 73% of hospitals, and were the antibiotic advisor in 25%. Pharmaceutical review of prescriptions was organised in almost all hospitals (97%). The univariable analysis identified five measures associated with lower overall antibiotic consumption: CPOE use (if >80% of prescriptions or 100%), pharmaceutical review (if >80% of beds or 100%) and the antibiotic advisor being a pharmacist (P=0.04, P=0.004 and P=0.003, respectively). In the multivariable analysis, two explanatory variables were significantly and independently associated with a lower overall antibiotic consumption: the antibiotic advisor being a pharmacist and a pharmaceutical review covering all beds (-19.9% [-31.6%; -8.1%], P=0.002 and -18.3% [-34.0%; -2.6%], P=0.03, respectively).

CONCLUSIONS

Antibiotic consumption was lower when the antibiotic advisor was a pharmacist and when the pharmaceutical team reviewed all prescriptions. These results highlight that actions initiated by pharmacists have a positive impact and should be supported.