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Del Fabro G, Venturini S, Avolio M, Basaglia G, Callegari A, Bramuzzo I, Basso B, Zanusso C, Rizzo A, Tonutti G, Chittaro M, Fiappo E, Tonizzo M, Crapis M. Time is running out. No excuses to delay implementation of antimicrobial stewardship programmes: impact, sustainability, resilience and efficiency through an interrupted time series analysis (2017-2022). JAC Antimicrob Resist 2024; 6:dlae072. [PMID: 38752207 PMCID: PMC11094472 DOI: 10.1093/jacamr/dlae072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Accepted: 04/20/2024] [Indexed: 05/18/2024] Open
Abstract
Introduction The WHO declared antimicrobial resistance (AMR) a significant concern in 2014, sparking initiatives to ensure responsible antibiotic use. In human medicine, Antimicrobial Stewardship Programmes (ASPs) in hospitals play a pivotal role in combating AMR. Although evidence supports the effectiveness of ASPs in optimizing antimicrobial use, often the lack of resources becomes an excuse to limit their dissemination and use. This paper provides a comprehensive report on a 6-year analysis of an ASP implemented in a healthcare region in north-east Italy. Methods A retrospective data collection was conducted to assess the programme's impact on antibiotic consumption expressed as DDDs/100 patient-days, its sustainability over time, resilience during the COVID-19 pandemic and the efficiency of the ASP (relationship between workload and human resources). Results A substantial overall reduction in antibiotic consumption (-14%), particularly in fluoroquinolones (-64%) and carbapenems (-68%), was demonstrated, showcasing the programme's impact. Sustainability was confirmed through enduring trends in antibiotic consumption and ecological analysis over time. The ASP demonstrates resilience by maintaining positive trends even amid the challenging COVID-19 pandemic. Efficiency was underscored by an increase in on-site consultations despite consistent human resources until 2021. Conclusions This study offers insights into the prolonged success of a resource-efficient ASP, emphasizing the crucial role of long-term commitment in fostering responsible antibiotic use in the context of global health challenges such as AMR.
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Affiliation(s)
- Giovanni Del Fabro
- Department of Infectious Diseases, ASFO ‘Santa Maria degli Angeli’ Hospital of Pordenone, via Montereale 24, Pordenone 33170, Italy
| | - Sergio Venturini
- Department of Infectious Diseases, ASFO ‘Santa Maria degli Angeli’ Hospital of Pordenone, via Montereale 24, Pordenone 33170, Italy
| | - Manuela Avolio
- Department of Microbiology, ASFO ‘Santa Maria degli Angeli’ Hospital of Pordenone, Pordenone, Italy
| | - Giancarlo Basaglia
- Department of Microbiology, ASFO ‘Santa Maria degli Angeli’ Hospital of Pordenone, Pordenone, Italy
| | - Astrid Callegari
- Department of Infectious Diseases, ASFO ‘Santa Maria degli Angeli’ Hospital of Pordenone, via Montereale 24, Pordenone 33170, Italy
| | - Igor Bramuzzo
- Department of Infectious Diseases, ASFO ‘Santa Maria degli Angeli’ Hospital of Pordenone, via Montereale 24, Pordenone 33170, Italy
| | - Barbara Basso
- Hospital Pharmacy, ASFO ‘Santa Maria degli Angeli’ Hospital of Pordenone, Pordenone, Italy
| | - Chiara Zanusso
- Hospital Pharmacy, ASFO ‘Santa Maria degli Angeli’ Hospital of Pordenone, Pordenone, Italy
| | - Anna Rizzo
- Hospital Pharmacy, ASFO ‘Santa Maria degli Angeli’ Hospital of Pordenone, Pordenone, Italy
| | - Giuseppe Tonutti
- Hospital Health Direction, ASFO ‘Santa Maria degli Angeli’ Hospital of Pordenone, Pordenone, Italy
| | - Michele Chittaro
- Hospital Health Direction, ASFO ‘Santa Maria degli Angeli’ Hospital of Pordenone, Pordenone, Italy
| | - Eva Fiappo
- Hospital Health Direction, ASFO ‘Santa Maria degli Angeli’ Hospital of Pordenone, Pordenone, Italy
| | - Maurizio Tonizzo
- Department of Internal Medicine, ASFO ‘Santa Maria degli Angeli’ Hospital of Pordenone, Pordenone, Italy
| | - Massimo Crapis
- Department of Infectious Diseases, ASFO ‘Santa Maria degli Angeli’ Hospital of Pordenone, via Montereale 24, Pordenone 33170, Italy
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Ngoma MT, Sitali D, Mudenda S, Mukuma M, Bumbangi FN, Bunuma E, Skjerve E, Muma JB. Community antibiotic consumption and associated factors in Lusaka district of Zambia: findings and implications for antimicrobial resistance and stewardship. JAC Antimicrob Resist 2024; 6:dlae034. [PMID: 38449513 PMCID: PMC10914457 DOI: 10.1093/jacamr/dlae034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 02/10/2024] [Indexed: 03/08/2024] Open
Abstract
Introduction Antimicrobial resistance (AMR) is a global public health crisis. This study assessed the general public's consumption of antibiotics and associated factors in the Lusaka district of Zambia. Methods This cross-sectional study was conducted among 2038 participants between December 2022 and January 2023. Data were analysed using Stata 13.0. Multivariable regression techniques were used to determine the factors that influenced antibiotic consumption. Results Of the 2038 participants, 53.4% were female, and 51.5% had attended at least secondary school. Antibiotic use was 99.2%, of which 40.9% were appropriately used. Overall, 79.1% of antibiotics were prescribed in hospitals, while 20.9% were used from leftovers and accessed without prescriptions. This study found that the appropriate use of antibiotics was associated with being female, being aged 35 years and above, attaining secondary school or tertiary education, having a monthly expenditure of 195 USD and above, being aware that antibiotics were not the same as painkillers, and being confident that when someone was hospitalized, they would get well. Conclusions This study found that the appropriate use of antibiotics was low, and this is an urgent public health issue requiring community engagement in tackling AMR and adherence to treatment guidelines in healthcare facilities. Additionally, there is a need to implement and strengthen antimicrobial stewardship programmes in healthcare facilities to promote the rational use of antibiotics in Zambia. There is also a need to heighten community awareness campaigns and educational activities on the appropriate use of antibiotics.
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Affiliation(s)
- Maty Tsumbu Ngoma
- Department of Disease Control, School of Veterinary Medicine, University of Zambia, Lusaka, Zambia
| | - Doreen Sitali
- Department of Health Promotion, School of Public Health, University of Zambia, Lusaka, Zambia
| | - Steward Mudenda
- Department of Pharmacy, School of Health Sciences, University of Zambia, Lusaka, Zambia
| | - Mercy Mukuma
- Department of Food Science, School of Agricultural Sciences and Nutrition, University of Zambia, Lusaka, Zambia
| | - Flavien Nsoni Bumbangi
- Department of Medicine and Clinical Sciences, School of Medicine, Eden University, Lusaka, Zambia
| | - Emmanuel Bunuma
- Department of Biomedical Sciences, School of Veterinary Medicine, University of Zambia, Lusaka, Zambia
| | - Eystein Skjerve
- Faculty of Veterinary Medicine, Norwegian University of Life Sciences, Ås, Norway
| | - John Bwalya Muma
- Department of Disease Control, School of Veterinary Medicine, University of Zambia, Lusaka, Zambia
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Yokoe DS, Advani SD, Anderson DJ, Babcock HM, Bell M, Berenholtz SM, Bryant KA, Buetti N, Calderwood MS, Calfee DP, Dubberke ER, Ellingson KD, Fishman NO, Gerding DN, Glowicz J, Hayden MK, Kaye KS, Klompas M, Kociolek LK, Landon E, Larson EL, Malani AN, Marschall J, Meddings J, Mermel LA, Patel PK, Perl TM, Popovich KJ, Schaffzin JK, Septimus E, Trivedi KK, Weinstein RA, Maragakis LL. Executive Summary: A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute-Care Hospitals: 2022 Updates. Infect Control Hosp Epidemiol 2023; 44:1540-1554. [PMID: 37606298 PMCID: PMC10587377 DOI: 10.1017/ice.2023.138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 06/01/2023] [Indexed: 08/23/2023]
Affiliation(s)
- Deborah S. Yokoe
- University of California San Francisco School of Medicine, UCSF Health-UCSF Medical Center, San Francisco, California, United States
| | - Sonali D. Advani
- Duke University School of Medicine, Durham, North Carolina, United States
| | | | - Hilary M. Babcock
- BJC Healthcare, Washington University School of Medicine, St. Louis, Missouri, United States
| | - Michael Bell
- Centers for Disease Control and Prevention, Atlanta, Georgia, United States
| | | | - Kristina A. Bryant
- Norton Healthcare, University of Louisville School of Medicine, Louisville, Kentucky, United States
| | - Niccolò Buetti
- Infection Control Programme, Geneva University Hospitals and Faculty of Medicine, World Health Organization Collaborating Center, Geneva, Switzerland
- IAME-U1137, Université Paris-Cité, INSERM, Paris, France
| | | | | | - Erik R. Dubberke
- Washington University School of Medicine, St. Louis, Missouri, United States
| | | | - Neil O. Fishman
- Penn Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Dale N. Gerding
- Edward Hines Jr. Veterans’ Affairs Hospital, Hines, Illinois, United States
| | - Janet Glowicz
- Centers for Disease Control and Prevention, Atlanta, Georgia, United States
| | - Mary K. Hayden
- Rush University Medical Center, Chicago, Illinois, United States
| | - Keith S. Kaye
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, United States
| | - Michael Klompas
- Harvard Medical School, Brigham and Women’s Hospital, Boston, Massachusetts, United States
| | - Larry K. Kociolek
- Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, United States
| | - Emily Landon
- The University of Chicago Medical Center, MacLean Center for Clinical Medical Ethics, Chicago, Illinois, United States
| | | | | | - Jonas Marschall
- Washington University School of Medicine, St. Louis, Missouri, United States
- Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jennifer Meddings
- University of Michigan Medical School, Ann Arbor, Michigan, United States
- Veterans’ Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, United States
| | - Leonard A. Mermel
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States
- Lifespan Hospital System, Providence, Rhode Island, United States
| | - Payal K. Patel
- Intermountain Healthcare, Salt Lake City, Utah, United States
| | - Trish M. Perl
- University of Texas Southwestern Medical Center, Dallas, Texas, United States
| | - Kyle J. Popovich
- Rush University Medical Center, Chicago, Illinois, United States
| | - Joshua K. Schaffzin
- Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Edward Septimus
- Texas A&M College of Medicine, Houston, Texas, United States
- Harvard Pilgrim Healthcare, Boston, Massachusetts, United States
| | - Kavita K. Trivedi
- Alameda County Public Health Department, San Leandro, California, United States
| | - Robert A. Weinstein
- Rush University Medical Center, Chicago, Illinois, United States
- Cook County Health, Chicago, Illinois, United States
| | - Lisa L. Maragakis
- Johns Hopkins University School of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland, United States
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Trivedi KK, Schaffzin JK, Deloney VM, Aureden K, Carrico R, Garcia-Houchins S, Garrett JH, Glowicz J, Lee GM, Maragakis LL, Moody J, Pettis AM, Saint S, Schweizer ML, Yokoe DS, Berenholtz S. Implementing strategies to prevent infections in acute-care settings. Infect Control Hosp Epidemiol 2023; 44:1232-1246. [PMID: 37431239 PMCID: PMC10527889 DOI: 10.1017/ice.2023.103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2023]
Abstract
This document introduces and explains common implementation concepts and frameworks relevant to healthcare epidemiology and infection prevention and control and can serve as a stand-alone guide or be paired with the "SHEA/IDSA/APIC Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals: 2022 Updates," which contain technical implementation guidance for specific healthcare-associated infections. This Compendium article focuses on broad behavioral and socio-adaptive concepts and suggests ways that infection prevention and control teams, healthcare epidemiologists, infection preventionists, and specialty groups may utilize them to deliver high-quality care. Implementation concepts, frameworks, and models can help bridge the "knowing-doing" gap, a term used to describe why practices in healthcare may diverge from those recommended according to evidence. It aims to guide the reader to think about implementation and to find resources suited for a specific setting and circumstances by describing strategies for implementation, including determinants and measurement, as well as the conceptual models and frameworks: 4Es, Behavior Change Wheel, CUSP, European and Mixed Methods, Getting to Outcomes, Model for Improvement, RE-AIM, REP, and Theoretical Domains.
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Affiliation(s)
| | - Joshua K. Schaffzin
- Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Valerie M. Deloney
- Society for Healthcare Epidemiology of America (SHEA), Arlington, Virginia
| | | | - Ruth Carrico
- Division of Infectious Diseases, University of Louisville School of Medicine, Louisville, Kentucky
| | | | - J. Hudson Garrett
- Division of Infectious Diseases, University of Louisville School of Medicine, Louisville, Kentucky
| | - Janet Glowicz
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Grace M. Lee
- Stanford Children’s Health, Stanford, California
| | | | - Julia Moody
- Clinical Services Group, HCA Healthcare, Nashville, Tennessee
| | | | - Sanjay Saint
- VA Ann Arbor Healthcare System and University of Michigan, Ann Arbor, Michigan
| | | | - Deborah S. Yokoe
- University of California San Francisco School of Medicine, UCSF Medical Center, San Francisco, California
| | - Sean Berenholtz
- Clinical Services Group, HCA Healthcare, Nashville, Tennessee
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Allerton F, Russell J. Antimicrobial stewardship in veterinary medicine: a review of online resources. JAC Antimicrob Resist 2023; 5:dlad058. [PMID: 37251304 PMCID: PMC10214461 DOI: 10.1093/jacamr/dlad058] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023] Open
Abstract
Background An awareness of antimicrobial resistance and stewardship is important for all prescribers from a One-Health perspective. Educational resources have been created to help veterinary practitioners and encourage an optimized approach to their antimicrobial use. Objectives To support veterinarians to select the most appropriate educational resource to meet their personal learning goals in relation to veterinary antimicrobial stewardship (AMS). Methods Modular online platforms, developed to promote AMS in veterinary practice (farm and companion animal), were reviewed and key features highlighted, including the required time commitment, resource type, focus and source as well as a subjective evaluation of resource accessibility (according to prior knowledge base). Results Five different online courses are described in this educational resource review: Antimicrobial stewardship in veterinary practice; Farm Vet Champions; Farmed Animal Antimicrobial Stewardship Initiative (FAAST); the Pathway of antimicrobial resistance (AMR) for a veterinary services professional; and the VetAMS online learning program. Each of these tools introduces users to key themes of veterinary AMS. Upon completion of any of the courses practitioners should feel confident to assume an active role as proponents of rational antimicrobial use. Significant differences between resources, relating to the focus (companion or farm animal), scope and depth of material covered, are recognized reflecting their respective target audiences. Conclusions Several informative and accessible resources, centred on the core principles of veterinary AMS, were reviewed. Key features have been highlighted to inform and guide resource-users towards the most appropriate tool for them. Greater engagement with these educational resources will hopefully contribute to improved antimicrobial prescribing among veterinarians and greater awareness of the importance of stewardship for the profession.
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Wojcik G, Ring N, Willis DS, Williams B, Kydonaki K. Improving antibiotic use in hospitals: development of a digital antibiotic review tracking toolkit (DARTT) using the behaviour change wheel. Psychol Health 2023:1-21. [PMID: 36855847 DOI: 10.1080/08870446.2023.2182894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 12/07/2022] [Accepted: 02/15/2023] [Indexed: 03/02/2023]
Abstract
OBJECTIVE To develop a theory-informed behaviour change intervention to promote appropriate hospital antibiotic use, guided by the Medical Research Council's complex interventions framework. METHODS A phased approach was used, including triangulation of data from meta-ethnography and two qualitative studies. Central to intervention design was the generation of a robust theoretical basis using the Behaviour Change Wheel to identify relevant determinants of behaviour change and intervention components. Intervention content was guided by APEASE (Acceptability, Practicability, Effectiveness, Affordability, Side-effects, and Equity) criteria and coded using a Behaviour Change Technique Taxonomy. Stakeholders were involved throughout. RESULTS From numerous modifiable prescribing behaviours identified, active 'antibiotic time-out' was selected as the target behaviour to help clinicians safely initiate antibiotic reassessment. Prescribers' capability, opportunity, and motivation were potential drivers for changing this behaviour. The design process resulted in the selection of 25 behaviour change techniques subsequently translated into intervention content. Integral to this work was the development and refinement of a Digital Antibiotic Review Tracking Toolkit. CONCLUSION This novel work demonstrates how the Behaviour Change Wheel can be used with the Medical Research Council framework to develop a theory-based behaviour change intervention targeting barriers to timely hospital antibiotic reassessment. Future research will evaluate the Antibiotic Toolkit's feasibility and effectiveness.
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Affiliation(s)
- Gosha Wojcik
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - N Ring
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - D S Willis
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - B Williams
- School of Health, Social Care & Life Sciences, University of Highlands and Islands, Inverness, UK
| | - K Kydonaki
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
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Goff DA, Mangino JE, Trolli E, Scheetz R, Goff D. Private Practice Dentists Improve Antibiotic Use After Dental Antibiotic Stewardship Education from Infectious Diseases Experts. Open Forum Infect Dis 2022; 9:ofac361. [PMID: 35959211 PMCID: PMC9361170 DOI: 10.1093/ofid/ofac361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 07/21/2022] [Indexed: 11/25/2022] Open
Abstract
Background Private practice dentists represent 72% of United States dentists. We conducted a prospective cohort study of private practice dentists comparing antibiotic use before and after dental antibiotic stewardship education by infectious diseases (ID) antibiotic stewardship experts. Methods Study phases were as follows: phase 1 (preeducation), 3 months of retrospective antibiotic data and a presurvey assessed baseline antibiotic knowledge; phase 2 (education), dentists attended 3 evening Zoom sessions; phase 3, (posteducation/interventions), 3 months of prospective audits with weekly feedback; phase 4, postsurvey and recommendations to reach more dentists. Results Fifteen dentists participated. Ten had practiced >20 years. Presurvey, 14 were unfamiliar with dental stewardship. The number of antibiotic prescriptions pre/post decreased from 2124 to 1816 (P < .00001), whereas procedures increased from 8526 to 9063. Overall, appropriate use (prophylaxis and treatment) increased from 19% pre to 87.9% post (P < .0001). Appropriate prophylaxis was 46.6% pre and 76.7% post (P < .0001). Joint implant prophylaxis decreased from 164 pre to 78 post (P < .0001). Appropriate treatment antibiotics pre/post improved 5-fold from 15% to 90.2% (P = .0001). Antibiotic duration pre/post decreased from 7.7 days (standard deviation [SD], 2.2 days) to 5.1 days (SD, 1.6 days) (P < .0001). Clindamycin use decreased 90% from 183 pre to 18 post (P < .0001). Postsurvey responses recommended making antibiotic stewardship a required annual continuing education. Study participants invited ID antibiotic stewardship experts to teach an additional 2125 dentists via dental study clubs. Conclusions After learning dental antibiotic stewardship from ID antibiotic stewardship experts, dentists rapidly optimized antibiotic prescribing. Private practice dental study clubs are expanding dental antibiotic stewardship training to additional dentists, hygienists, and patients across the United States.
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Affiliation(s)
- Debra A Goff
- The Ohio State University Wexner Medical Center, The Ohio State University College of Pharmacy ; 410 W. 10th Avenue, Columbus, OH 43210 USA
| | - Julie E Mangino
- The Division of Infectious Diseases in the Department of Internal Medicine at The Ohio State University College of Medicine 1581 Dodd Drive, Suite 400, Columbus OH 43210 USA
| | - Elizabeth Trolli
- The Ohio State University College of Pharmacy 410 W 10th Ave. Columbus OH 43210 USA
| | - Richard Scheetz
- Dr. Scheetz Oral and Facial Surgeon of Ohio 5155 Bradenton Ave, Dublin, OH 43017 USA
| | - Douglas Goff
- Dr’s. Gilbert and Goff Prosthodontists 3360 Tremont Rd. #120, Columbus, OH 43221 USA
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Studying Factors Affecting Success of Antimicrobial Resistance Interventions through the Lens of Experience: A Thematic Analysis. Antibiotics (Basel) 2022; 11:antibiotics11050639. [PMID: 35625282 PMCID: PMC9137464 DOI: 10.3390/antibiotics11050639] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 05/02/2022] [Accepted: 05/03/2022] [Indexed: 02/06/2023] Open
Abstract
Antimicrobial resistance (AMR) affects the environment, and animal and human health. Institutions worldwide have applied various measures, some of which have reduced antimicrobial use and AMR. However, little is known about factors influencing the success of AMR interventions. To address this gap, we engaged health professionals, designers, and implementers of AMR interventions in an exploratory study to learn about their experience and factors that challenged or facilitated interventions and the context in which interventions were implemented. Based on participant input, our thematic analysis identified behaviour; institutional governance and management; and sharing and enhancing information as key factors influencing success. Important sub-themes included: correct behaviour reinforcement, financial resources, training, assessment, and awareness of AMR. Overall, interventions were located in high-income countries, the human sector, and were publicly funded and implemented. In these contexts, behaviour patterns strongly influenced success, yet are often underrated or overlooked when designing AMR interventions. Improving our understanding of what contributes to successful interventions would allow for better designs of policies that are tailored to specific contexts. Exploratory approaches can provide encouraging results in complex challenges, as made evident in our study. Remaining challenges include more engagement in this type of study by professionals and characterisation of themes that influence intervention outcomes by context.
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Abstract
Antibiotic use (and misuse) accelerates antimicrobial resistance (AMR), and addressing this complex problem necessitates behaviour change related to infection prevention and management and to antibiotic prescribing and use. As most antibiotic courses are prescribed in primary care, a key focus of antimicrobial stewardship (AMS) is on changing behaviours outside of hospital. Behavioural science draws on behaviour change theories, techniques and methods developed in health psychology, and can be used to help understand and change behaviours related to AMR/AMS. Qualitative methodologies can be used together with a behavioural science approach to explore influences on behaviour and develop and evaluate behavioural interventions. This paper provides an overview of how the behavioural science approach, together with qualitative methods, can contribute and add value to AMS projects. First, it introduces and explains the relevance of the behavioural science approach to AMR/AMS. Second, it provides an overview of behaviour change ‘tools’: behaviour change theories/models, behavioural determinants and behaviour change techniques. Third, it explains how behavioural methods can be used to: (i) define a clinical problem in behavioural terms and identify behavioural influences; (ii) develop and implement behavioural AMS interventions; and (iii) evaluate them. These are illustrated with examples of using qualitative methods in AMS studies in primary care. Finally, the paper concludes by summarizing the main contributions of taking the behavioural science approach to qualitative AMS research in primary care and discussing the key implications and future directions for research and practice.
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Affiliation(s)
- Aleksandra J. Borek
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Corresponding author. E-mail:
| | - Marta Santillo
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Marta Wanat
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Christopher C. Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- National Institute for Health Research (NIHR) Health Protection Research Unit (HPRU) in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- National Institute for Health Research (NIHR) Health Protection Research Unit (HPRU) in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
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Nampoothiri V, Bonaconsa C, Surendran S, Mbamalu O, Nambatya W, Ahabwe Babigumira P, Ahmad R, Castro-Sanchez E, Broom A, Szymczak J, Zingg W, Gilchrist M, Holmes A, Mendelson M, Singh S, McLeod M, Charani E. What does antimicrobial stewardship look like where you are? Global narratives from participants in a massive open online course. JAC Antimicrob Resist 2021; 4:dlab186. [PMID: 34988443 PMCID: PMC8713011 DOI: 10.1093/jacamr/dlab186] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 11/05/2021] [Indexed: 11/13/2022] Open
Abstract
Background Whilst antimicrobial stewardship (AMS) is being implemented globally, contextual differences exist. We describe how the use of a massive open online course (MOOC) platform provided an opportunity to gather diverse narratives on AMS from around the world. Methods A free 3 week MOOC titled ‘Tackling antimicrobial resistance: a social science approach’ was launched in November 2019. Learners were asked specific questions about their experiences of AMS via 38 optional free-text prompts dispersed throughout the modules. Content analysis was used to identify key emerging themes from the learners’ responses in the first three runs of the MOOC. Results Between November 2019 and July 2020, 1464 learners enrolled from 114 countries. Overall, 199 individual learners provided a total of 1097 responses to the prompts. The diverse perspectives describe unique challenges present in different contexts including ill-defined roles for pharmacists and nurses in AMS; inadequate governance and policy inconsistencies in surveillance for antibiotic consumption and antimicrobial resistance (AMR) in some countries; lack of ownership of antibiotic decision-making and buy-in from different clinical specialties; and human resource and technological constraints. Patients’ knowledge, experiences and perspectives were recognized as a valuable source of information that should be incorporated in AMS initiatives to overcome cultural barriers to the judicious use of antibiotics. Conclusions Analysis of learner comments and reflections identified a range of enablers and barriers to AMS implementation across different healthcare economies. Common challenges to AMS implementation included the role of non-physician healthcare workers, resource limitations, gaps in knowledge of AMR, and patient engagement and involvement in AMS.
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Affiliation(s)
| | | | - Surya Surendran
- Department of Infection Control and Epidemiology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham University, Kochi, Kerala, India
| | - Oluchi Mbamalu
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Winnie Nambatya
- Department of Pharmacy, Makerere University, Kampala, Uganda
| | | | - Raheelah Ahmad
- Division of Health Services Research and Management, School of Health Sciences, University of London, London, UK
| | - Enrique Castro-Sanchez
- Division of Health Services Research and Management, School of Health Sciences, University of London, London, UK
| | - Alex Broom
- Department of Sociology and Social Policy, School of Social and Political Sciences, The University of Sydney, Sydney, Australia
| | - Julia Szymczak
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Walter Zingg
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, Zurich, Switzerland
| | - Mark Gilchrist
- Department of Pharmacy, Imperial College Healthcare NHS Trust, London, UK
| | - Alison Holmes
- Health Protection Research Unit in Healthcare Associated infections and Antimicrobial Resistance, Department of Medicine, Imperial College London, London, UK
| | - Marc Mendelson
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Sanjeev Singh
- Department of Infection Control and Epidemiology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham University, Kochi, Kerala, India
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11
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Cave R, Cole J, Mkrtchyan HV. Surveillance and prevalence of antimicrobial resistant bacteria from public settings within urban built environments: Challenges and opportunities for hygiene and infection control. ENVIRONMENT INTERNATIONAL 2021; 157:106836. [PMID: 34479136 PMCID: PMC8443212 DOI: 10.1016/j.envint.2021.106836] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 08/12/2021] [Accepted: 08/15/2021] [Indexed: 05/09/2023]
Abstract
Antimicrobial resistant (AMR) bacteria present one of the biggest threats to public health; this must not be forgotten while global attention is focussed on the COVID-19 pandemic. Resistant bacteria have been demonstrated to be transmittable to humans in many different environments, including public settings in urban built environments where high-density human activity can be found, including public transport, sports arenas and schools. However, in comparison to healthcare settings and agriculture, there is very little surveillance of AMR in the built environment outside of healthcare settings and wastewater. In this review, we analyse the existing literature to aid our understanding of what surveillance has been conducted within different public settings and identify what this tells us about the prevalence of AMR. We highlight the challenges that have been reported; and make recommendations for future studies that will help to fill knowledge gaps present in the literature.
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Affiliation(s)
- Rory Cave
- School of Biomedical Sciences, University of West London, United Kingdom
| | - Jennifer Cole
- Royal Holloway University of London, Department of Health Studies, United Kingdom
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12
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Broom A, Doron A. Resistant bugs, porous borders and ecologies of care in India. Soc Sci Med 2021; 292:114520. [PMID: 34740470 DOI: 10.1016/j.socscimed.2021.114520] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 10/26/2021] [Accepted: 10/27/2021] [Indexed: 11/28/2022]
Abstract
As social science scholarship has routinely illustrated, professional practice is rarely as contained or coherent as it is often imagined to be. The increasing emphasis on the rise of antimicrobial resistance (AMR) has drawn renewed attention to the interconnectedness of clinic, community, environment and planet, and how proposed 'solutions' to major problems such as AMR require a broad, cross-cutting lens. In this study, set in Hyderabad, India, we draw on a series of interviews with hospital-based clinicians completed during 2019 and early 2020, to unpack the multidimensional, ecological acceleration of AMR and the implications for everyday practice. Their accounts make visible how practice operates in relation to industrial economies, community vulnerabilities, and ecologies. This in turn highlights the problem of epistemic bordering, where 'sites' of AMR are targeted but are prone to leakage and transgressions. We propose an ecological approach to conceptualising antimicrobial practices with implications for AMR interventions being rolled out in the sub-continent and beyond.
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Affiliation(s)
- Alex Broom
- Sydney Centre for Healthy Societies, School of Social and Political Sciences, The University of Sydney, New South Wales, Australia.
| | - Assa Doron
- College of Asia & the Pacific, The Australian National University, Australian Capital Territory, Australia.
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13
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Charani E, McKee M, Ahmad R, Balasegaram M, Bonaconsa C, Merrett GB, Busse R, Carter V, Castro-Sanchez E, Franklin BD, Georgiou P, Hill-Cawthorne K, Hope W, Imanaka Y, Kambugu A, Leather AJM, Mbamalu O, McLeod M, Mendelson M, Mpundu M, Rawson TM, Ricciardi W, Rodriguez-Manzano J, Singh S, Tsioutis C, Uchea C, Zhu N, Holmes AH. Optimising antimicrobial use in humans - review of current evidence and an interdisciplinary consensus on key priorities for research. THE LANCET REGIONAL HEALTH. EUROPE 2021; 7:100161. [PMID: 34557847 PMCID: PMC8454847 DOI: 10.1016/j.lanepe.2021.100161] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Addressing the silent pandemic of antimicrobial resistance (AMR) is a focus of the 2021 G7 meeting. A major driver of AMR and poor clinical outcomes is suboptimal antimicrobial use. Current research in AMR is inequitably focused on new drug development. To achieve antimicrobial security we need to balance AMR research efforts between development of new agents and strategies to preserve the efficacy and maximise effectiveness of existing agents. Combining a review of current evidence and multistage engagement with diverse international stakeholders (including those in healthcare, public health, research, patient advocacy and policy) we identified research priorities for optimising antimicrobial use in humans across four broad themes: policy and strategic planning; medicines management and prescribing systems; technology to optimise prescribing; and context, culture and behaviours. Sustainable progress depends on: developing economic and contextually appropriate interventions; facilitating better use of data and prescribing systems across healthcare settings; supporting appropriate and scalable technological innovation. Implementing this strategy for AMR research on the optimisation of antimicrobial use in humans could contribute to equitable global health security.
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Affiliation(s)
- Esmita Charani
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, UK
- Division of Infectious Diseases & HIV Medicine, Department of Medicine, University of Cape Town, South Africa
| | - Martin McKee
- London School of Hygiene and Tropical Medicine, London, UK
| | - Raheelah Ahmad
- School of Health Sciences City, University of London, UK
| | - Manica Balasegaram
- The Global Antibiotic Research and Development Partnership, Geneva, Switzerland
| | - Candice Bonaconsa
- Division of Infectious Diseases & HIV Medicine, Department of Medicine, University of Cape Town, South Africa
| | | | | | - Vanessa Carter
- Stanford University Medicine X e-Patient Scholars Program 2017, Health Communication and Social Media South Africa, Africa CDC Civil Society Champion for AMR
| | - Enrique Castro-Sanchez
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, UK
| | - Bryony D Franklin
- University College London School of Pharmacy, London, UK
- Imperial College Healthcare NHS Trust, Centre for Medication Safety and Service Quality, Pharmacy Department, London, UK
| | - Pantelis Georgiou
- Department of Electrical and Electronic Engineering, Faculty of Engineering, Imperial College London, London, UK
| | - Kerri Hill-Cawthorne
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, UK
| | - William Hope
- Department of Molecular and Clinical Pharmacology, University of Liverpool, UK
| | - Yuichi Imanaka
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Andrew Kambugu
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Andrew JM Leather
- King's Centre for Global Health and Health Partnerships, School of Population Health and Environmental Sciences, King's College London, London, UK
| | - Oluchi Mbamalu
- Division of Infectious Diseases & HIV Medicine, Department of Medicine, University of Cape Town, South Africa
| | - M McLeod
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, UK
- Imperial College Healthcare NHS Trust, Centre for Medication Safety and Service Quality, Pharmacy Department, London, UK
| | - Marc Mendelson
- Division of Infectious Diseases & HIV Medicine, Department of Medicine, University of Cape Town, South Africa
| | | | - Timothy M Rawson
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, UK
- Department of Bioengineering, Imperial College London, London, UK
| | | | - Jesus Rodriguez-Manzano
- Department of Electrical and Electronic Engineering, Faculty of Engineering, Imperial College London, London, UK
- Department of Infectious Diseases, Faculty of Medicine, Imperial College London, London
| | - Sanjeev Singh
- Department of Infection Control and Epidemiology, Amrita Institute of Medical Science, Amrita Vishwa Vidyapeetham, Kochi (Kerala), India
| | - Constantinos Tsioutis
- Department of Internal Medicine and Infection Prevention and Control, School of Medicine, European University Cyprus, Nicosia, Cyprus
| | - Chibuzor Uchea
- Drug-Resistant Infections Priority Programme,Wellcome Trust, London, UK
| | - Nina Zhu
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, UK
| | - Alison H Holmes
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, UK
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14
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Johnson MC, Hulgan T, Cooke RG, Kleinpell R, Roumie C, Callaway-Lane C, Mitchell LD, Hathaway J, Dittus R, Staub M. Operationalising outpatient antimicrobial stewardship to reduce system-wide antibiotics for acute bronchitis. BMJ Open Qual 2021; 10:bmjoq-2020-001275. [PMID: 34210668 PMCID: PMC8252871 DOI: 10.1136/bmjoq-2020-001275] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 06/06/2021] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Antibiotics are not recommended for treatment of acute uncomplicated bronchitis (AUB), but are often prescribed (85% of AUB visits within the Veterans Affairs nationally). This quality improvement project aimed to decrease antibiotic prescribing for AUB in community-based outpatient centres from 65% to <32% by April 2020. METHODS From January to December 2018, community-based outpatient clinics' 6 months' average of prescribed antibiotics for AUB and upper respiratory infections was 63% (667 of 1054) and 64.6% (314 of 486) when reviewing the last 6 months. Seven plan-do-study-act (PDSA) cycles were implemented by an interprofessional antimicrobial stewardship team between January 2019 and March 2020. Balancing measures were a return patient phone call or visit within 4 weeks for the same complaint. Χ2 tests and statistical process control charts using Western Electric rules were used to analyse intervention data. RESULTS The AUB antibiotic prescribing rate decreased from 64.6% (314 of 486) in the 6 months prior to the intervention to 36.8% (154 of 418) in the final 6 months of the intervention. No change was seen in balancing measures. The largest reduction in antibiotic prescribing was seen after implementation of PDSA 6 in which 14 high prescribers were identified and targeted for individualised reviews of encounters of patients with AUB with an antimicrobial steward. CONCLUSIONS Operational implementation of successful stewardship interventions is challenging and differs from the traditional implementation study environment. As a nascent outpatient stewardship programme with limited resources and no additional intervention funding, we successfully reduced antibiotic prescribing from 64.6% to 36.8%, a reduction of 43% from baseline. The most success was seen with targeted education of high prescribers.
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Affiliation(s)
- Morgan Clouse Johnson
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System Nashville Campus, Nashville, Tennessee, USA
| | - Todd Hulgan
- Infectious Diseases, VA Tennessee Valley Healthcare System Nashville Campus, Nashville, Tennessee, USA.,Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Robin G Cooke
- Pharmacy, VA Tennessee Valley Healthcare System Nashville Campus, Nashville, Tennessee, USA
| | - Ruth Kleinpell
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System Nashville Campus, Nashville, Tennessee, USA.,School of Nursing, Vanderbilt University, Nashville, Tennessee, USA
| | - Christianne Roumie
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System Nashville Campus, Nashville, Tennessee, USA.,Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Carol Callaway-Lane
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System Nashville Campus, Nashville, Tennessee, USA
| | - Lauren D Mitchell
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System Nashville Campus, Nashville, Tennessee, USA
| | - Jacob Hathaway
- Primary Care, VA Tennessee Valley Healthcare System Nashville Campus, Nashville, Tennessee, USA
| | - Robert Dittus
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System Nashville Campus, Nashville, Tennessee, USA.,Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Milner Staub
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System Nashville Campus, Nashville, Tennessee, USA.,Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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15
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Isenor JE, Bai I, Cormier R, Helwig M, Reeve E, Whelan AM, Burgess S, Martin-Misener R, Kennie-Kaulbach N. Deprescribing interventions in primary health care mapped to the Behaviour Change Wheel: A scoping review. Res Social Adm Pharm 2020; 17:1229-1241. [PMID: 32978088 DOI: 10.1016/j.sapharm.2020.09.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 06/17/2020] [Accepted: 09/07/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND Polypharmacy and inappropriate medication use are an increasing concern. Deprescribing may improve medication use through planned and supervised dose reduction or stopping of medications. As most medication management occurs in primary health care, which is generally described as the first point of access for day-to-day care, deprescribing in primary health care is the focus on this review. OBJECTIVE This scoping review aimed to identify and characterize strategies for deprescribing in primary health care and map the strategies to the Behaviour Change Wheel (BCW). METHODS A scoping review was conducted that involved searches of six databases (2002-2018) and reference lists of relevant systematic reviews and included studies. Studies that described and evaluated deprescribing strategies in primary health care were eligible. Two independent reviewers screened articles and completed data charting with charting verified by a third. Deprescribing strategies were mapped to the intervention functions of the BCW and linked to specific Behaviour Change Techniques (BCT). RESULTS Searches yielded 6871 citations of which 43 were included. Nineteen studies were randomized, 24 were non-randomized. Studies evaluated deprescribing in terms of medication changes, feasibility, and prescriber/patient perspectives. Deprescribing strategies involved various professionals (physicians, pharmacists, nurses), as well as patients and were generally multifaceted. A wide range of intervention functions were identified, with 41 BCTs mapped to Environmental restructuring, 38 BCTs mapped to Enablement, and 34 BCTs mapped to Persuasion. CONCLUSIONS Deprescribing strategies in primary health care have used a variety of BCTs to address individual professionals (e.g. education) as well as strategies that addressed the practice setting, including support from additional team members (e.g. pharmacists, nurses and patients). Further research is warranted to determine comparative effectiveness of different BCTs, which can help facilitate implementation of deprescribing strategies, thereby reducing polypharmacy, in primary health care.
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Affiliation(s)
- Jennifer E Isenor
- College of Pharmacy, Dalhousie University, 5968 College Street, Halifax, NS, Canada.
| | - Isaac Bai
- College of Pharmacy, Dalhousie University, 5968 College Street, Halifax, NS, Canada
| | - Rachel Cormier
- College of Pharmacy, Dalhousie University, 5968 College Street, Halifax, NS, Canada
| | - Melissa Helwig
- W.K. Kellogg Health Sciences Library, Dalhousie University, Halifax, NS, Canada
| | - Emily Reeve
- College of Pharmacy, Dalhousie University, 5968 College Street, Halifax, NS, Canada; Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Division of Health Sciences, University of South Australia, Adelaide, SA, Australia; Geriatric Medicine Research, Faculty of Medicine, Dalhousie University and Nova Scotia Health Authority, Halifax, NS, Canada
| | - Anne Marie Whelan
- College of Pharmacy, Dalhousie University, 5968 College Street, Halifax, NS, Canada
| | - Sarah Burgess
- Pharmacy Department, Nova Scotia Health Authority, Halifax, NS, Canada
| | - Ruth Martin-Misener
- School of Nursing, Dalhousie University, 5869 University Avenue, Halifax, NS, Canada
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16
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Paiva JA, Mergulhão P, Salluh JIF. What every intensivist must know about antimicrobial stewardship: its pitfalls and its challenges. Rev Bras Ter Intensiva 2020; 32:207-212. [PMID: 32667443 PMCID: PMC7405748 DOI: 10.5935/0103-507x.20200037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Accepted: 11/04/2019] [Indexed: 11/29/2022] Open
Affiliation(s)
- José-Artur Paiva
- Departamento de Medicina Intensiva, Centro Hospitalar Universitário São João, Porto, Portugal
| | - Paulo Mergulhão
- Departamento de Medicina Intensiva, Centro Hospitalar Universitário São João, Porto, Portugal
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17
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Rzewuska M, Duncan EM, Francis JJ, Morris AM, Suh KN, Davey PG, Grimshaw JM, Ramsay CR. Barriers and Facilitators to Implementation of Antibiotic Stewardship Programmes in Hospitals in Developed Countries: Insights From Transnational Studies. FRONTIERS IN SOCIOLOGY 2020; 5:41. [PMID: 33869448 PMCID: PMC8022532 DOI: 10.3389/fsoc.2020.00041] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 05/12/2020] [Indexed: 06/12/2023]
Abstract
Objectives: To identify perceived influences on implementation of antibiotic stewardship programmes (ASPs) in hospitals, across healthcare systems, and to exemplify the use of a behavioral framework to conceptualize those influences. Methods: EMBASE and MEDLINE databases were searched from 01/2001 to 07/2017 and reference lists were screened for transnational studies that reported barriers and/or facilitators to implementing actual or hypothetical ASPs or ASP-supporting strategies. Extracted data were synthesized using content analysis with the Theoretical Domains Framework as an organizing framework. Commonly reported influences were quantified. Results: From 3,196 abstracts 75 full-text articles were screened for inclusion. Eight studies met the eligibility criteria. The number of countries involved in each study ranged from 2 to 36. These studies included a total of 1849 participants. North America, Europe and Australasia had the strongest representation. Participants were members of special interest groups, designated hospital representatives or clinical experts. Ten of the 14 theoretical domains in the framework were present in the results reported in the included studies. The most commonly reported (≥4 out of 8 studies) influences on ASP implementation were coded in the domain "environmental context and resources" (e.g., problems with data and information systems; lack of key personnel; inadequate financial resources) and "goals" (other higher priorities). Conclusions: Despite an extensive transnational research effort, there is evidence from international studies of substantial barriers to implementing ASPs in hospitals, even in developed countries. Large-scale efforts to implement hospital antibiotic stewardship in those countries will need to overcome issues around inadequacy of information systems, unavailability of key personnel and funding, and the competition from other priority initiatives. We have enhanced the evidence base to inform guidance by taking a behavioral approach to identify influences on ASP uptake. Systematic review registration: PROSPERO registration number CRD42017076425.
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Affiliation(s)
- Magdalena Rzewuska
- Health Services Research Unit, University of Aberdeen, Aberdeen, United Kingdom
| | - Eilidh M. Duncan
- Health Services Research Unit, University of Aberdeen, Aberdeen, United Kingdom
| | - Jill J. Francis
- School of Health Sciences, City University of London, London, United Kingdom
| | - Andrew M. Morris
- Department of Medicine, Sinai Health System and University Health Network, Toronto, ON, Canada
- Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Kathryn N. Suh
- Department of Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Peter G. Davey
- Division of Population Health & Genomics, Medical School, University of Dundee, Dundee, United Kingdom
| | - Jeremy M. Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Craig R. Ramsay
- Health Services Research Unit, University of Aberdeen, Aberdeen, United Kingdom
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18
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Rogers Van Katwyk S, Hoffman SJ, Mendelson M, Taljaard M, Grimshaw JM. Strengthening the science of addressing antimicrobial resistance: a framework for planning, conducting and disseminating antimicrobial resistance intervention research. Health Res Policy Syst 2020; 18:60. [PMID: 32513200 PMCID: PMC7278195 DOI: 10.1186/s12961-020-00549-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 03/17/2020] [Indexed: 12/12/2022] Open
Abstract
Antimicrobial resistance (AMR) has the potential to threaten tens of millions of lives and poses major global economic and development challenges. As the AMR threat grows, it is increasingly important to strengthen the scientific evidence base on AMR policy interventions, to learn from existing policies and programmes, and to integrate scientific evidence into the global AMR response.While rigorous evaluations of AMR policy interventions are the ideal, they are far from the current reality. To strengthen this evidence base, we describe a framework for planning, conducting and disseminating research on AMR policy interventions. The framework identifies challenges in AMR research, areas for enhanced coordination and cooperation with decision-makers, and best practices in the design of impact evaluations for AMR policies.This framework offers a path forward, enabling increased local and global cooperation, and overcoming common limitations in existing research on AMR policy interventions.
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Affiliation(s)
- S Rogers Van Katwyk
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.
- Global Strategy Lab, Dahdaleh Institute for Global Health Research, Faculty of Health and Osgoode Hall Law School, York University, Toronto, ON, Canada.
| | - S J Hoffman
- Department of Health Research Methods, Evidence, and Impact and McMaster Health Forum, McMaster University, Hamilton, ON, Canada
- Department of Global Health & Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, United States of America
| | - M Mendelson
- Division of Infectious Diseases and HIV Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - M Taljaard
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - J M Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
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19
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Szymczak JE. Are Surgeons Different? The Case for Bespoke Antimicrobial Stewardship. Clin Infect Dis 2020; 69:21-23. [PMID: 30445615 DOI: 10.1093/cid/ciy847] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 09/28/2018] [Indexed: 12/30/2022] Open
Affiliation(s)
- Julia E Szymczak
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania.,Division of Infectious Diseases, Hospital of the University of Pennsylvania, Philadelphia
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20
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Muntwyler N, Dubois MS, Weese JS. Retrospective assessment of perioperative antimicrobial use for elective arthroscopy in horses. Vet Surg 2020; 49:427-435. [PMID: 31950522 DOI: 10.1111/vsu.13382] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 12/16/2019] [Accepted: 01/03/2020] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To describe perioperative antimicrobial use in horses undergoing elective arthroscopy. STUDY DESIGN Retrospective study. SAMPLE POPULATION Horses that underwent elective arthroscopy at one institution between July 2016 and May 2018, excluding those with a suspected infectious orthopedic disease or with a comorbidity that may have impacted prophylactic antimicrobial use decisions. METHODS Medical records were reviewed to evaluate preoperative, intraoperative, and postoperative antimicrobial drug selection, dose, and timing. Associations between body weight and underdosing were evaluated by using analysis of variance, χ2 test was used for categorical comparisons, and least squares fit was used to evaluate factors associated with duration of postoperative antimicrobials. RESULTS Among 150 horses, 149 (99.3%) received systemic preoperative antimicrobials. Only 53 (40.2%) horses were administered doses within 60 minutes of surgical incision. First incision was performed more than two half-lives after administration of sodium penicillin in 46 of 131 (35.1%) horses but in only 1 of 106 (0.8%) horses that received trimethoprim-sulfadoxine. Body weight was associated with underdosing for penicillin (P = .0075) and trimethoprim-sulfadoxine (P = .002) but not gentamicin (P = .92). Twenty-six (17%) horses received one postoperative antimicrobial dose, while antimicrobials were continued in hospital for a mean of 22.3 ± 4.4 hours after surgery in the other 123 horses. Among the 149 discharged horses, 115 (77.2%) were prescribed antimicrobials after discharge (range, 3-10 days; median, 3 days, interquartile range, 0 days). CONCLUSION Deviations from common recommendations were apparent and provide evidence for the requirement to develop interventions to optimize perioperative prophylaxis. CLINICAL SIGNIFICANCE Perioperative antimicrobial use practices should be regularly assessed to provide a benchmark and identify areas for intervention.
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Affiliation(s)
- Noah Muntwyler
- Ontario Veterinary College, University of Guelph, Guelph, Ontario, Canada
| | | | - J Scott Weese
- Ontario Veterinary College, University of Guelph, Guelph, Ontario, Canada
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21
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Resman F. Antimicrobial stewardship programs; a two-part narrative review of step-wise design and issues of controversy Part I: step-wise design of an antimicrobial stewardship program. Ther Adv Infect Dis 2020; 7:2049936120933187. [PMID: 32612826 PMCID: PMC7307277 DOI: 10.1177/2049936120933187] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 05/11/2020] [Indexed: 12/27/2022] Open
Abstract
Regardless of one's opinion of 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 includes not only aspects of infectious disease and microbiology, but also of epidemiology, genetics, behavioural psychology, systems science, economics and ethics, to name a few. This review aims to take several of these aspects and the scientific evidence of 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. This first part 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. The second part, published separately, formulates ten 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
- Department of Translational Medicine, Clinical
Infection Medicine, Lund University, Rut Lundskogs Gata 3, Plan 6, Malmö, 20502,
Sweden
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22
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Allen JM, Dunn R, Bush J. Effect of prescriber peer comparison reports on fluoroquinolone use across a 16‐facility community hospital system. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2019. [DOI: 10.1002/jac5.1106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- John M. Allen
- Department of Pharmacotherapy and Translational Research University of Florida College of Pharmacy Orlando Florida
- Department of Internal Medicine University of Central Florida College of Medicine Orlando Florida
| | - Ryan Dunn
- HealthTrust Supply Chain, West Florida Division Largo Florida
| | - Jeffrey Bush
- HealthTrust Supply Chain, West Florida Division Largo Florida
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23
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Diagnostic accuracy and adherence to treatment guidelines in adult inpatients with urinary tract infections in a tertiary hospital. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2019. [DOI: 10.1002/jppr.1508] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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24
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Sneddon J, Barlow G, Bradley S, Brink A, Chandy SJ, Nathwani D. Development and impact of a massive open online course (MOOC) for antimicrobial stewardship. J Antimicrob Chemother 2019; 73:1091-1097. [PMID: 29340600 DOI: 10.1093/jac/dkx493] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 11/29/2017] [Indexed: 11/13/2022] Open
Abstract
Background The University of Dundee and the BSAC developed a massive open online course (MOOC) to address the global need for education to support antimicrobial stewardship in low- and middle-income countries. Methods An interactive course, Antimicrobial Stewardship: Managing Antibiotic Resistance, was developed and delivered via the FutureLearn© platform. The course ran over four 6 week periods during 2015 and 2016 supported by educators and was evaluated via data on uptake and feedback from learners on impact on clinical practice. Results In total, 32 944 people, 70% of them healthcare professionals, from 163 countries joined the course from Europe (49%), Asia (16%), Africa (13%), North America (9%), Australia (8%) and South America (5%). Between 33% and 37% of joiners in each run completed at least one step in any week of the course and 219 participants responded to a post-course survey. The course was rated good or excellent by 208 (95%) of the participants, and 83 (38%) intended to implement stewardship interventions in their own setting. A follow-up survey 6 months later suggested that 49% had implemented such interventions. Conclusions The MOOC has addressed a global learning need by providing education free at the point of access, and learning from its development will help others embarking upon similar educational solutions. Initial quantitative and qualitative feedback suggests it has engaged participants and complements traditional educational methods. Measuring its real impact on clinical practice remains a challenge. The FutureLearn© platform offers flexibility for MOOCs to be sustainable through modification to remove educator facilitation but maintain active participant discussion.
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Affiliation(s)
- Jacqueline Sneddon
- Scottish Antimicrobial Prescribing Group, Healthcare Improvement Scotland, 50 West Nile Street, Glasgow, Scotland
| | - Gavin Barlow
- Department of Infection, Hull & East Yorkshire Hospitals NHS Trust, Anlaby Road, Hull, England
| | - Sally Bradley
- British Society for Antimicrobial Chemotherapy, 53 Regent Place, Birmingham, England
| | - Adrian Brink
- Ampath National Laboratory Services, Milpark Hospital, Johannesburg, South Africa.,Division of Infectious Diseases and HIV Medicine, Groote Schuur Hospital and Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Sujith J Chandy
- Department of Pharmacology & Clinical Pharmacology, Christian Medical College, Vellore, India
| | - Dilip Nathwani
- British Society for Antimicrobial Chemotherapy, 53 Regent Place, Birmingham, England.,University of Dundee Medical School, Dundee, Scotland
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25
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Dickson A, Smith M, Smith F, Park J, King C, Currie K, Langdridge D, Davis M, Flowers P. Understanding the relationship between pet owners and their companion animals as a key context for antimicrobial resistance-related behaviours: an interpretative phenomenological analysis. Health Psychol Behav Med 2019; 7:45-61. [PMID: 34040838 PMCID: PMC8114347 DOI: 10.1080/21642850.2019.1577738] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 01/28/2019] [Indexed: 12/24/2022] Open
Abstract
Objectives: Drivers of antimicrobial resistance (AMR) are diffuse and complex including a range of interspecies behaviours between pet owners and their animals. We employed interpretative phenomenological analysis (IPA) to explore the relationship between pet owners and their companion animals in relation to AMR. Design: Cross sectional, qualitative study. Methods: Semi-structured interviews were conducted with twenty-three British pet owners, transcribed verbatim and subjected to Interpretative Phenomenological Analysis (IPA). Results: Three, inter-related Superordinate themes are presented 1) 'They're my fur babies': unconditional love and anthropomorphism; 2) 'They share everything with you': affection and transmission behaviours; and 3) 'We would err on the side of caution': decision making and antibiotic use'. Conclusions: Affectionate behaviours between companion animals and their owners pose a risk for AMR transmission but they are so deeply treasured that they are unlikely to be amenable to change. In contrast, the promotion of appropriate antibiotic stewardship for pet owners and vets may offer a viable pathway for intervention development, benefitting from synergies with other interventions that target prescribers.
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Affiliation(s)
- A. Dickson
- Safeguarding Health through Infection Prevention [SHIP] Research Group, Glasgow Caledonian University, Glasgow, Scotland
| | - M. Smith
- Safeguarding Health through Infection Prevention [SHIP] Research Group, Glasgow Caledonian University, Glasgow, Scotland
| | - F. Smith
- Safeguarding Health through Infection Prevention [SHIP] Research Group, Glasgow Caledonian University, Glasgow, Scotland
| | - J. Park
- Safeguarding Health through Infection Prevention [SHIP] Research Group, Glasgow Caledonian University, Glasgow, Scotland
| | - C. King
- Safeguarding Health through Infection Prevention [SHIP] Research Group, Glasgow Caledonian University, Glasgow, Scotland
| | - K. Currie
- Safeguarding Health through Infection Prevention [SHIP] Research Group, Glasgow Caledonian University, Glasgow, Scotland
| | - D. Langdridge
- Faculty of Arts and Social Sciences, Open University, Milton Keynes, England
| | - M. Davis
- School of Social Sciences, Monash University, Melbourne, Australia
| | - P. Flowers
- Safeguarding Health through Infection Prevention [SHIP] Research Group, Glasgow Caledonian University, Glasgow, Scotland
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26
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Antibiotic Stewardship-Twenty Years in the Making. Antibiotics (Basel) 2019; 8:antibiotics8010007. [PMID: 30678365 PMCID: PMC6466570 DOI: 10.3390/antibiotics8010007] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 01/09/2019] [Accepted: 01/21/2019] [Indexed: 11/21/2022] Open
Abstract
In the last 20 years, efforts were made to optimize antibiotic use in hospitals across the world as a means of addressing the increasing threat of antibiotic resistance. Despite robust evidence supporting optimal practice, antibiotic decision-making remains sub-optimal in many settings, including in hospitals. Globally, resources remain a limiting factor in the implementation of antibiotic stewardship programs. In addition, antibiotic decision-making is a social process dependent on cultural and contextual factors. Cultural boundaries in healthcare and across specialties still limit the involvement of allied healthcare professionals in stewardship interventions. There is variation in the social norms and antibiotic-prescribing behaviors between specialties in hospitals. The cultural differences between specialties and healthcare professionals (1) shape the shared knowledge within and across specialties in the patient pathway, and (2) result in variation in care, thus impacting patient outcomes. Bespoke stewardship interventions that account for contextual variation in practice are necessary.
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27
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Rzewuska M, Charani E, Clarkson JE, Davey PG, Duncan EM, Francis JJ, Gillies K, Kern WV, Lorencatto F, Marwick CA, McEwen J, Möhler R, Morris AM, Ramsay CR, Rogers Van Katwyk S, Skodvin B, Smith I, Suh KN, Grimshaw JM. Prioritizing research areas for antibiotic stewardship programmes in hospitals: a behavioural perspective consensus paper. Clin Microbiol Infect 2018; 25:163-168. [PMID: 30195471 DOI: 10.1016/j.cmi.2018.08.020] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 08/16/2018] [Accepted: 08/23/2018] [Indexed: 12/19/2022]
Abstract
SCOPE Antibiotic stewardship programmes (ASPs) are necessary in hospitals to improve the judicious use of antibiotics. While ASPs require complex change of key behaviours on individual, team organization and policy levels, evidence from the behavioural sciences is underutilized in antibiotic stewardship studies across the world, including high-income countries (HICs). A consensus procedure was performed to propose research priority areas for optimizing effective implementation of ASPs in hospital settings using a behavioural perspective. METHODS A workgroup for behavioural approaches to ASPs was convened in response to the fourth call for leading expert network proposals by the Joint Programming Initiative on Antimicrobial Resistance (JPIAMR). Eighteen clinical and academic specialists in antibiotic stewardship, implementation science and behaviour change from four HICs with publicly funded healthcare systems (e.g. Canada, Germany, Norway and the UK) met face-to-face to agree on broad research priority areas using a structured consensus method. Question addressed and recommendations: The consensus process assessing the ten identified research priority areas resulted in recommendations that need urgent scientific interest and funding to optimize effective implementation of ASPs for hospital inpatients in HICs with publicly funded healthcare systems. We suggest and detail behavioural science evidence-guided research efforts in the following areas: (a) comprehensively identifying barriers and facilitators to implementing ASPs and clinical recommendations intended to optimize antibiotic prescribing; (b) identifying actors ('who') and actions ('what needs to be done') of ASPs and clinical teams; (c) synthesizing available evidence to support future research and planning for ASPs; (d) specifying the activities in current ASPs with the purpose of defining a control group for comparison with new initiatives; (e) defining a balanced set of outcomes and measures to evaluate the effects of interventions focused on reducing unnecessary exposure to antibiotics; (f) conducting robust evaluations of ASPs with built-in process evaluations and fidelity assessments; (g) defining and designing ASPs; (h) establishing the evidence base for impact of ASPs on resistance; (i) investigating the role and impact of government and policy contexts on ASPs; and (j) understanding what matters to patients in ASPs in hospitals. CONCLUSIONS Assessment, revisions and updates of our priority-setting exercise should be considered at intervals of 2 years. To propose research priority areas in low- and middle-income countries, the methodology reported here could be applied.
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Affiliation(s)
- M Rzewuska
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK.
| | - E Charani
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
| | - J E Clarkson
- Schools of Dentistry, University of Dundee, Dundee, UK
| | - P G Davey
- Division of Population Health Sciences, Medical School, University of Dundee, Dundee, London, UK
| | - E M Duncan
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - J J Francis
- School of Health Sciences, City University of London, London, UK
| | - K Gillies
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - W V Kern
- University of Freiburg Medical Center and Faculty of Medicine, Division of Infectious Diseases, Freiburg, Germany
| | - F Lorencatto
- Centre for Behaviour Change, University College London, London, UK
| | - C A Marwick
- Division of Population Health Sciences, Medical School, University of Dundee, Dundee, London, UK
| | | | - R Möhler
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center and Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - A M Morris
- Sinai Health System, University Health Network and University of Toronto, Toronto, Canada
| | - C R Ramsay
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - S Rogers Van Katwyk
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - B Skodvin
- Norwegian Advisory Unit for Antibiotic Use in Hospitals, Haukeland University Hospital, Bergen, Norway
| | - I Smith
- Department of Essential Medicines and Health Products, World Health Organization, Geneva, Switzerland
| | - K N Suh
- Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, Canada
| | - J M Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute and Department of Medicine, University of Ottawa, Ottawa, Canada
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28
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McParland JL, Williams L, Gozdzielewska L, Young M, Smith F, MacDonald J, Langdridge D, Davis M, Price L, Flowers P. What are the 'active ingredients' of interventions targeting the public's engagement with antimicrobial resistance and how might they work? Br J Health Psychol 2018; 23:804-819. [PMID: 29804314 PMCID: PMC6175406 DOI: 10.1111/bjhp.12317] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 04/25/2018] [Indexed: 12/23/2022]
Abstract
Objectives Changing public awareness of antimicrobial resistance (AMR) represents a global public health priority. A systematic review of interventions that targeted public AMR awareness and associated behaviour was previously conducted. Here, we focus on identifying the active content of these interventions and explore potential mechanisms of action. Methods The project took a novel approach to intervention mapping utilizing the following steps: (1) an exploration of explicit and tacit theory and theoretical constructs within the interventions using the Theoretical Domains Framework (TDFv2), (2) retrospective coding of behaviour change techniques (BCTs) using the BCT Taxonomy v1, and (3) an investigation of coherent links between the TDF domains and BCTs across the interventions. Results Of 20 studies included, only four reported an explicit theoretical basis to their intervention. However, TDF analysis revealed that nine of the 14 TDF domains were utilized, most commonly ‘Knowledge’ and ‘Environmental context and resources’. The BCT analysis showed that all interventions contained at least one BCT, and 14 of 93 (15%) BCTs were coded, most commonly ‘Information about health consequences’, ‘Credible source’, and ‘Instruction on how to perform the behaviour’. Conclusions We identified nine relevant TDF domains and 14 BCTs used in these interventions. Only 15% of BCTs have been applied in AMR interventions thus providing a clear opportunity for the development of novel interventions in this context. This methodological approach provides a useful way of retrospectively mapping theoretical constructs and BCTs when reviewing studies that provide limited information on theory and intervention content. Statement of contribution What is already known on this subject? Evidence of the effectiveness of interventions that target the public to engage them with AMR is mixed; the public continue to show poor knowledge and misperceptions of AMR. Little is known about the common, active ingredients of AMR interventions targeting the public and information on explicit theoretical content is sparse. Information on the components of AMR public health interventions is urgently needed to enable the design of effective interventions to engage the public with AMR stewardship behaviour.
What does this study add? The analysis shows very few studies reported any explicit theoretical basis to the interventions they described. Many interventions share common components, including core mechanisms of action and behaviour change techniques. The analysis suggests components of future interventions to engage the public with AMR.
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Affiliation(s)
| | - Lynn Williams
- School of Psychological Sciences and Health, University of Strathclyde, Glasgow, UK
| | | | - Mairi Young
- Institute for Applied Health, Glasgow Caledonian University, UK
| | - Fraser Smith
- Institute for Applied Health, Glasgow Caledonian University, UK
| | | | - Darren Langdridge
- Faculty of Arts and Social Sciences, The Open University, Milton Keynes, UK
| | - Mark Davis
- School of Sciences, Monash University, Melbourne, Victoria, Australia
| | - Lesley Price
- Institute for Applied Health, Glasgow Caledonian University, UK
| | - Paul Flowers
- Institute for Applied Health, Glasgow Caledonian University, UK
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29
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Manchanda V, Suman U, Singh N. Implementing Infection Prevention and Control Programs When Resources Are Limited. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2018. [DOI: 10.1007/s40506-018-0142-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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30
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Parsonage B, Hagglund PK, Keogh L, Wheelhouse N, Brown RE, Dancer SJ. Control of Antimicrobial Resistance Requires an Ethical Approach. Front Microbiol 2017; 8:2124. [PMID: 29163414 PMCID: PMC5673829 DOI: 10.3389/fmicb.2017.02124] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Accepted: 10/18/2017] [Indexed: 01/18/2023] Open
Abstract
Ethical behavior encompasses actions that benefit both self and society. This means that tackling antimicrobial resistance (AMR) becomes an ethical obligation, because the prospect of declining anti-infectives affects everyone. Without preventive action, loss of drugs that have saved lives over the past century, will condemn ourselves, people we know, and people we don't know, to unacceptable risk of untreatable infection. Policies aimed at extending antimicrobial life should be considered within an ethical framework, in order to balance the choice, range, and quality of drugs against stewardship activities. Conserving availability and effectiveness for future use should not compromise today's patients. Practices such as antimicrobial prophylaxis for healthy people 'at risk' should receive full debate. There are additional ethical considerations for AMR involving veterinary care, agriculture, and relevant bio-industries. Restrictions for farmers potentially threaten the quality and quantity of food production with economic consequences. Antibiotics for companion animals do not necessarily spare those used for humans. While low-income countries cannot afford much-needed drugs, pharmaceutical companies are reluctant to develop novel agents for short-term return only. Public demand encourages over-the-counter, internet, black market, and counterfeit drugs, all of which compromise international control. Prescribers themselves require educational support to balance therapeutic choice against collateral damage to both body and environment. Predicted mortality due to AMR provides justification for international co-operation, commitment and investment to support surveillance and stewardship along with development of novel antimicrobial drugs. Ethical arguments for, and against, control of antimicrobial resistance strategies are presented and discussed in this review.
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Affiliation(s)
- Ben Parsonage
- Department of Engineering, University of Strathclyde, Glasgow, United Kingdom
| | - Philip K Hagglund
- Department of Engineering, Luleå University of Technology, Luleå, Sweden
| | - Lloyd Keogh
- Department of Engineering, University of Strathclyde, Glasgow, United Kingdom
| | - Nick Wheelhouse
- School of Applied Sciences, Edinburgh Napier University, Edinburgh, United Kingdom
| | - Richard E Brown
- Department of Engineering, University of Strathclyde, Glasgow, United Kingdom.,Sophrodyne Ltd., Glasgow, United Kingdom
| | - Stephanie J Dancer
- School of Applied Sciences, Edinburgh Napier University, Edinburgh, United Kingdom.,Department of Microbiology, Hairmyres Hospital, NHS Lanarkshire, Bothwell, United Kingdom
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31
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Chavada R, Walker HN, Tong D, Murray A. Changes in antimicrobial prescribing behavior after the introduction of the antimicrobial stewardship program: A pre- and post-intervention survey. Infect Dis Rep 2017; 9:7268. [PMID: 29071048 PMCID: PMC5641660 DOI: 10.4081/idr.2017.7268] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 08/23/2017] [Accepted: 08/25/2017] [Indexed: 12/02/2022] Open
Abstract
The introduction of an antimicrobial stewardship (AMS) program is associated with a change in antimicrobial prescribing behavior. A proposed mechanism for this change is by impacting the prescribing etiquette described in qualitative studies. This study sought to detect a change in prescribing attitudes 12 months after the introduction of AMS and gauge utility of various AMS interventions. Surveys were distributed to doctors in two regional Australian hospitals on a convenience basis 6 months before, and 12 months after, the introduction of AMS. Agreement with 20 statements describing attitudes (cultural, behavioral and knowledge) towards antimicrobial prescribing was assessed on a 4-point Likert scale. Mean response scores were compared using the Wilcoxon Rank sum test. 155 responses were collected before the introduction of AMS, and 144 afterwards. After the introduction of AMS, an increase was observed in knowledge about available resources such as electronic decision support systems (EDSS) and therapeutic guidelines, with raised awareness about the support available through AMS rounds and the process to be followed when prescribing restricted antimicrobials. Additionally, doctors were less likely to rely on pharmacy to ascertain when an antimicrobial was restricted, depend on infectious diseases consultant advice and use past experience to guide antimicrobial prescribing. Responses to this survey indicate that positive changes to the antimicrobial prescribing etiquette may be achieved with the introduction of an AMS program. Use of EDSS and other resources such as evidence-based guidelines are perceived to be important to drive rational antimicrobial prescribing within AMS programs.
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Affiliation(s)
- Ruchir Chavada
- Department of Microbiology and Infectious Diseases, Pathology North Central Coast
| | - Harry N Walker
- Division of Medicine, Central Coast Local Health District
| | - Deborah Tong
- Pharmacy Department, Central Coast Local Health District, NSW, Australia
| | - Amy Murray
- Pharmacy Department, Central Coast Local Health District, NSW, Australia
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32
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Singh N, Manchanda V. Control of multidrug-resistant Gram-negative bacteria in low- and middle-income countries-high impact interventions without much resources. Clin Microbiol Infect 2017; 23:216-218. [PMID: 28274769 DOI: 10.1016/j.cmi.2017.02.034] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Accepted: 02/27/2017] [Indexed: 11/28/2022]
Affiliation(s)
- N Singh
- George Washington University, Children's National Health System, Washington DC, USA.
| | - V Manchanda
- Maulana Azad Medical College, New Delhi, India
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