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Resman F. Antimicrobial stewardship programs; a two-part narrative review of step-wise design and issues of controversy. Part II: Ten questions reflecting knowledge gaps and issues of controversy in the field of antimicrobial stewardship. Ther Adv Infect Dis 2020; 7:2049936120945083. [PMID: 32913648 PMCID: PMC7443983 DOI: 10.1177/2049936120945083] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 06/30/2020] [Indexed: 01/15/2023] Open
Abstract
Regardless of one's opinion on antimicrobial stewardship programs (ASPs), it is hardly possible to work in hospital care and not be exposed to the term or its practical effects. Despite the term being relatively new, the number of publications in the field is vast, including several excellent reviews of general and specific aspects. Work in antimicrobial stewardship is complex, and include aspects not only of infectious disease and microbiology, but also of epidemiology, genetics, behavioural psychology, systems science, economics and ethics, to name but a few. This review aims to take several of these aspects and the scientific evidence from antimicrobial stewardship studies and merge them into two questions: How should we design ASPs based on what we know today? and Which are the most essential unanswered questions regarding antimicrobial stewardship on a broader scale? This narrative review is written in two separate parts aiming to provide answers to the two questions. The first part, published separately, is written as a step-wise approach to designing a stewardship intervention based on the pillars of unmet need, feasibility, scientific evidence and necessary core elements. It is written mainly as a guide to someone new to the field. It is sorted into five distinct steps; (a) focusing on designing aims; (b) assessing performance and local barriers to rational antimicrobial use; (c) deciding on intervention technique; (d) practical, tailored design including core element inclusion; and (e) evaluation and sustainability. This second part formulates 10 critical questions on controversies in the field of antimicrobial stewardship. It is aimed at clinicians and researchers with stewardship experience and strives to promote discussion, not to provide answers.
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Affiliation(s)
- Fredrik Resman
- Clinical Infection Medicine, Department of
Translational Medicine, Lund University, Rut Lundskogs gata 3, plan 6, Malmö,
20502, Sweden
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Moral Responsibility and the Justification of Policies to Preserve Antimicrobial Effectiveness. ETHICS AND DRUG RESISTANCE: COLLECTIVE RESPONSIBILITY FOR GLOBAL PUBLIC HEALTH 2020. [DOI: 10.1007/978-3-030-27874-8_9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Abstract
Restrictive policies that limit antimicrobial consumption, including therapeutically justified use, might be necessary to tackle the problem of antimicrobial resistance. We argue that such policies would be ethically justified when forgoing antimicrobials constitutes a form of easy rescue for an individual. These are cases of mild and self-limiting infections in otherwise healthy patients whose overall health is not significantly compromised by the infection. In such cases, restrictive policies would be ethically justified because they would coerce individuals into fulfilling a moral obligation they independently have. However, to ensure that such justification is the strongest possible, states also have the responsibility to ensure that forgoing antimicrobials is as easy as possible for patients by implementing adequate compensation measures.
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Gillespie D, Francis NA, Carrol ED, Thomas-Jones E, Butler CC, Hood K. Use of co-primary outcomes for trials of antimicrobial stewardship interventions. THE LANCET. INFECTIOUS DISEASES 2019; 18:595-597. [PMID: 29856347 DOI: 10.1016/s1473-3099(18)30289-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Accepted: 04/27/2018] [Indexed: 11/15/2022]
Affiliation(s)
- David Gillespie
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK.
| | - Nick A Francis
- Division of Population Medicine, School of Medicine, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Enitan D Carrol
- University of Liverpool Institute of Infection and Global Health, Liverpool, UK
| | - Emma Thomas-Jones
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Kerenza Hood
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
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Montrucchio G, Sales G, Corcione S, De Rosa FG, Brazzi L. Choosing wisely: what is the actual role of antimicrobial stewardship in Intensive Care Units? Minerva Anestesiol 2018; 85:71-82. [PMID: 29991221 DOI: 10.23736/s0375-9393.18.12662-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
More than two-thirds of critically ill patients receive an antimicrobial therapy with a percentage between 30% and 50% of all prescribed antibiotics reported to be unnecessary, inappropriate or misused. Since inappropriate prescription of antibiotic drugs concurs to dissemination of the multidrug resistant organisms, a reasoned antibiotics use is crucial especially in Intensive Care Unit (ICU), where up to 60% of the admitted patients develops an infection during their ICU stay. Even if the concept of antimicrobial stewardship (AS) has been clearly described as a series of coordinated interventions designed to improve antimicrobial agents use, few studies are reporting about its effectiveness to improve outcomes, reduce adverse events and costs and decrease resistance rate spread. Moreover, although it is recognized that AS programs are particularly indicated in the critical setting due to the huge number of antimicrobial drugs used, the optimal characteristics of these interventions and the best system to evaluate their effectiveness are still unclear. Specific interventions, designed tacking into account the peculiarities of the ICU setting, are hence necessary to set-up an "in-ICU-stewardship," including prompt identification of infected patients, selection of appropriate empiric treatments, optimization of dosing and route of administration, improvement of diagnostic techniques, early de-escalation to achieve shorter duration and avoid unnecessary therapies. The present narrative review summarizes the "state of art" about AS programmes and discusses the effects of the interventions possibly applied in ICU setting to optimize the patient's treatment, reduce the micro-organisms resistance and contain the hospital resources utilization.
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Affiliation(s)
| | - Gabriele Sales
- Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Silvia Corcione
- Department of Medical Sciences, Infectious Diseases, University of Turin, Turin, Italy
| | - Francesco G De Rosa
- Department of Medical Sciences, Infectious Diseases, University of Turin, Turin, Italy
| | - Luca Brazzi
- Department of Surgical Sciences, University of Turin, Turin, Italy.,Department of Anaesthesia, Intensive Care and Emergency, "Città della Salute e della Scienza" Hospital, Turin, Italy
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Kamenshchikova A, Wolffs PFG, Hoebe CJ, Penders J, Horstman K. Complex narratives of health, stigma and control: Antimicrobial resistance screening among non-hospitalized refugees. Soc Sci Med 2018; 212:43-49. [PMID: 30005223 DOI: 10.1016/j.socscimed.2018.07.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 06/27/2018] [Accepted: 07/06/2018] [Indexed: 01/23/2023]
Abstract
Antimicrobial resistance (AMR) is often presented as a major public health problem globally. Screening for AMR usually takes place in clinical settings. Recent developments in microbiology stimulated a series of studies focusing on AMR in communities, and particularly in travelers (any mobile individual), which was argued to be important for identifying potential public health risks. Against this background, microbiologists have become interested in non-hospitalized refugees as one of the traveler groups. However, this attention to refugees has provoked some professional debates on potential stigmatization of refugees as dangerous "others". To contribute to these debates, and to explore the idea of AMR screening of non-hospitalized refugees from different perspectives, we conducted a qualitative study among four groups of stakeholders who were chosen because of their associations with potential microbiological screening: microbiologists, public health physicians, public health nurses, and refugees. The study took place in a Dutch city from June to August 2016 and had 17 participants: five microbiologists, two public health nurses, four public health physicians, and six refugees. While microbiologists and public health physicians demonstrated a de-contextualized biomedical narrative in arguing that AMR screening among non-hospitalized refugees could be important for scientific research as well as for AMR prevention in communities, public health nurses displayed a more contextualized narrative bringing the benefits for individuals at the center and indicating that screening exclusively among refugees may provoke fear and stigmatization. Refugees were rather positive about AMR screening but stressed that it should particularly contribute to their individual health. We conclude that to design AMR prevention strategies, it is important to consider the complex meanings of AMR screening, and to design these strategies as a process of co-production by diverse stakeholders, including the target populations.
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Affiliation(s)
- A Kamenshchikova
- Department of Health, Ethics and Society, School of Public Health and Primary Care (CAPHRI), Maastricht University, Postbus 616, 6200, MD, Maastricht, the Netherlands; Research Centre for Policy Analysis and Studies of Technologies (PAST-Centre), National Research Tomsk State University, Tomsk, Russian Federation.
| | - P F G Wolffs
- Department of Medical Microbiology, School of Public Health and Primary Care (CAPHRI), Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands
| | - C J Hoebe
- Department of Medical Microbiology, School of Public Health and Primary Care (CAPHRI), Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands; Department of Sexual Health, Infectious Diseases and Environmental Health, South Limburg Public Health Service (GGD South Limburg), Heerlen, the Netherlands
| | - J Penders
- Department of Medical Microbiology, School of Public Health and Primary Care (CAPHRI), Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands; Department of Medical Microbiology, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands
| | - K Horstman
- Department of Health, Ethics and Society, School of Public Health and Primary Care (CAPHRI), Maastricht University, Postbus 616, 6200, MD, Maastricht, the Netherlands
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Bringedal B, Isaksson Rø K, Magelssen M, Førde R, Aasland OG. Between professional values, social regulations and patient preferences: medical doctors' perceptions of ethical dilemmas. JOURNAL OF MEDICAL ETHICS 2018; 44:239-243. [PMID: 29151056 DOI: 10.1136/medethics-2017-104408] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Revised: 10/16/2017] [Accepted: 11/07/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND We present and discuss the results of a Norwegian survey of medical doctors' views on potential ethical dilemmas in professional practice. METHODS The study was conducted in 2015 as a postal questionnaire to a representative sample of 1612 doctors, among which 1261 responded (78%). We provided a list of 41 potential ethical dilemmas and asked whether each was considered a dilemma, and whether the doctor would perform the task, if in a position to do so. Conceptually, dilemmas arise because of tensions between two or more of four doctor roles: the patient's advocate, a steward of societal interests, a member of a profession and a private individual. RESULTS 27 of the potential dilemmas were considered dilemmas by at least 50% of the respondents. For more than half of the dilemmas, the anticipated course of action varied substantially within the professional group, with at least 20% choosing a different course than their colleagues, indicating low consensus in the profession. CONCLUSIONS Doctors experience a large range of ethical dilemmas, of which many have been given little attention by academic medical ethics. The less-discussed dilemmas are characterised by a low degree of consensus in the profession about how to handle them. There is a need for medical ethicists, medical education, postgraduate courses and clinical ethics support to address common dilemmas in clinical practice. Viewing dilemmas as role conflicts can be a fruitful approach to these discussions.
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Affiliation(s)
- Berit Bringedal
- LEFO, Institute for Studies of the Medical Profession, Oslo, Norway
| | | | - Morten Magelssen
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Reidun Førde
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway
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