'It makes life so much easier'-experiences of users of the MicroGuide™ smartphone app for improving antibiotic prescribing behaviour in UK hospitals: an interview study

Antimicrobial stewardship markers and healthcare-associated pneumonia threshold criteria in UK hospitals: analysis of the MicroGuideTm application

Background

To address antimicrobial resistance, antimicrobial stewardship (AMS) principles must be implemented and adhered to. Clinical decision aids such as the MicroGuideTM app are an important part of these efforts. We sought to evaluate the consistency of core AMS information and the diversity of classification thresholds for healthcare-associated pneumonia (HAP) in the MicroGuide app.

Methods

Guidelines in the MicroGuide app were extracted and analysed for content related to AMS and HAP. Guidelines were characterized according to HAP naming classification; community-acquired pneumonia (CAP) classifications were analysed to serve as a comparator group.

Results

In total, 115 trusts (119 hospitals) were included. Nearly all hospitals had developed MicroGuide sections on AMS (n = 112/119, 94%) and sepsis management (n = 117/119, 98%). Other AMS sections were outpatient parenteral antimicrobial therapy (47%), antifungal stewardship (70%), critical care (23%) and IV to oral switch therapy (83%). Only 9% of hospitals included guidance on the maximum six key AMS sections identified. HAP definitions varied widely across hospitals with some classifying by time to onset and some classifying by severity or complexity. The largest proportion of HAP guidelines based classification on severity/complexity (n = 69/119, 58%). By contrast, definitions in CAP guidelines were uniform.

Conclusions

The high heterogeneity in HAP classification identified suggests inconsistency of practice in identifying thresholds for HAP in the UK. This complicates HAP management and AMS practices. To address HAP in alignment with AMS principles, a comprehensive strategy that prioritizes uniform clinical definitions and thresholds should be developed.

Use of the Microguide mobile phone application for ENT conditions: a national review

OBJECTIVE

Smartphone applications are used widely in healthcare, including antimicrobial applications such as Microguide. There has been no review of hospitals using this smartphone application for ENT conditions.

METHODS

This study analysed all hospital accounts using Microguide and examined the ENT conditions that were listed.

RESULTS

In total, 123 hospitals were included in this study; 45 ENT-related conditions were listed on Microguide across all hospitals, with an average of 8 conditions listed per hospital.

CONCLUSION

There is a significant disparity of ENT conditions listed on Microguide. A suggested list is recommended to be included for ENT departments using Microguide, to help improve antimicrobial stewardship for the specialty.

Addressing the Challenges of Penicillin Allergy Delabeling With Electronic Health Records and Mobile Applications

Allergy labels are common, often incorrect, and potentially harmful. There are many opportunities for clinical decision support (CDS) tools integrated in the electronic health record (EHR) and mobile apps to address the challenges with drug allergy management, including penicillin allergy delabeling (PADL). Effective delabeling solutions must consider multidisciplinary clinical workflow and multistep processes, including documentation, assessment, plan (eg, allergy testing and referral), record update, drug allergy alert management, and allergy reconciliation over time. Developing a systematic infrastructure to manage allergies across the EHR is critical to improve the accuracy and completeness of a patient's allergy and avoid inadvertently relabeling. Improving the appropriateness and relevancy of drug allergy alerts is important to reduce alert fatigue. Using alerts to guide clinicians on appropriate antibiotic use may reduce unnecessary β-lactam avoidance. To date, EHR CDS tools have facilitated non-allergists to provide PADL at the point of care. A mobile app was shown to support PADL and provide specialist support and education. Future research is needed to standardize, integrate, and evaluate innovative CDS tools in the EHR to demonstrate patient safety and clinical utility and facilitate wider adoption.

Tipping the balance: A systematic review and meta-ethnography to unfold the complexity of surgical antimicrobial prescribing behavior in hospital settings

Surgical specialties account for a high proportion of antimicrobial use in hospitals, and misuse has been widely reported resulting in unnecessary patient harm and antimicrobial resistance. We aimed to synthesize qualitative studies on surgical antimicrobial prescribing behavior, in hospital settings, to explain how and why contextual factors act and interact to influence practice. Stakeholder engagement was integrated throughout to ensure consideration of varying interpretive repertoires and that the findings were clinically meaningful. The meta-ethnography followed the seven phases outlined by Noblit and Hare. Eight databases were systematically searched without date restrictions. Supplementary searches were performed including forwards and backwards citation chasing and contacting first authors of included papers to highlight further work. Following screening, 14 papers were included in the meta-ethnography. Repeated reading of this work enabled identification of 48 concepts and subsequently eight overarching concepts: hierarchy; fear drives action; deprioritized; convention trumps evidence; complex judgments; discontinuity of care; team dynamics; and practice environment. The overarching concepts interacted to varying degrees but there was no consensus among stakeholders regarding an order of importance. Further abstraction of the overarching concepts led to the development of a conceptual model and a line-of-argument synthesis, which posits that social and structural mediators influence individual complex antimicrobial judgements and currently skew practice towards increased and unnecessary antimicrobial use. Crucially, our model provides insights into how we might ‘tip the balance’ towards more evidence-based antimicrobial use. Currently, healthcare workers deploy antimicrobials across the surgical pathway as a safety net to allay fears, reduce uncertainty and risk, and to mitigate against personal blame. Our synthesis indicates that prescribing is unlikely to change until the social and structural mediators driving practice are addressed. Furthermore, it suggests that research specifically exploring the context for effective and sustainable quality improvement stewardship initiatives in surgery is now urgent.

Understanding of Future Prescribers About Antimicrobial Resistance and Their Preparedness Towards Antimicrobial Stewardship Activities in Pakistan: Findings and Implications

Background: Insufficient antimicrobial-related training for physicians during their undergraduate education could have a negative impact on their prescribing. Unlike previous studies, this study not only explored the understanding and perception of Pakistani medical students about antibiotics and resistance, but also their preparedness towards antimicrobial stewardship programs. Methods: An online cross-sectional study was undertaken with final-year medical students using a validated questionnaire from January 2021 to May 2021. Descriptive and inference statistics were applied for data analysis. Results: Of 411 students, only 6.3% had undergone antimicrobial resistance (AMR) training. 16.1% of students believed that antibiotics are effective for viral ailments. More than half of the students agreed that AMR is a major healthcare problem in Pakistan (65.9%). Most students viewed poor infection control practices (66.9%), the use of too many broad-spectrum antibiotics (68.4%) for a longer duration (62.8%) with inadequate doses (67.9%) as the causes of AMR. The student's preparation was insufficient in interpreting microbiological and pathological results (26.3%), selecting the correct antibiotics (22.1%), and awareness of the antibiotic spectrum (20.9%). The median preparedness score showed significant differences with sex (p = 0.049), age (p < 0.001), institute type (p = 0.014), and family income (p = 0.006). Conclusion: Pakistani medical students showed adequate understanding of antibiotics, but lacked preparedness for several components of ASPs, including interpretation of microbiological results and spectrum of antibiotics. More steps need to be taken to prepare medical students for AMR and stewardship initiatives adequately.