Nurse roles in antimicrobial stewardship: lessons from public sectors models of acute care service delivery in the United Kingdom

Knowledge of antimicrobial stewardship and the Access, Watch and Reserve (AWaRe) classification of antibiotics among frontline healthcare professionals in Akwa Ibom State, Nigeria: a cross-sectional study

BACKGROUND

Antimicrobial stewardship (AMS) aims to improve antibiotic use while reducing resistance and its consequences. There is a paucity of data on the availability of AMS programmes in southern Nigeria. Further, there is no data on Nigerian healthcare professionals' knowledge of the WHO 'Access, Watch and Reserve' (AWaRe) classification of antibiotics. This study sought to assess knowledge of AMS and the AWaRe classification of antibiotics among frontline healthcare professionals in Akwa Ibom State, Nigeria.

METHODS

This was a cross-sectional survey of 417 healthcare professionals, comprising medical doctors, pharmacists and nurses, across 17 public hospitals in Akwa Ibom State, Nigeria. A paper-based self-completion questionnaire was used to collect data from the participants during working hours between September and November 2023. Statistical analysis was done using SPSS version 25.0, with p < 0.05 indicating statistical significance.

RESULTS

Four hundred and seventeen out of the 500 healthcare professionals approached agreed to participate, giving an 83.4% response rate. Most of the participants were female (62.1%) and nurses (46.3%). Approximately 57% of participants were familiar with the term antibiotic/antimicrobial stewardship, however, only 46.5% selected the correct description of AMS. Majority (53.0%) did not know if AMS programme was available in their hospitals. 79% of participants did not know about AWaRe classification of antibiotics. Among the 87 (20.9%) who knew, 28.7% correctly identified antibiotics into the AWaRe groups from a given list. Only profession significantly predicted knowledge of AMS and awareness of the AWaRe classification of antibiotics (p < 0.001). Pharmacists were more likely to define AMS correctly than medical doctors (odds ratio [OR] = 2.02, 95% confidence interval [CI] = 1.16-3.52, p = 0.012), whereas nurses were less likely to be aware of the WHO AWaRe classification of antibiotics than medical doctors (OR = 0.36, 95% CI = 0.18-0.72, p = 0.004).

CONCLUSIONS

There was a notable knowledge deficit in both AMS and the AWaRe classification of antibiotics among participants in this study. This highlights the need for educational interventions targeted at the different cadres of healthcare professionals on the role of AMS programmes in reducing antimicrobial resistance and its consequences.

Nurses' attitudes, behaviours, and enablers of intravenous to oral switching (IVOS) of antibiotics: a mixed-methods survey of nursing staff in secondary care hospitals across the Midlands region of England

BACKGROUND

Intravenous (IV) antibiotic use in secondary care in England is widespread. Timely appropriate intravenous to oral switch (IVOS) has the potential to deliver significant clinical and operational benefits. To date, antimicrobial stewardship (AMS) efforts around IVOS have not focused on the nursing staff who administer antibiotics, which represents a significant gap in AMS programmes.

AIM

To determine the involvement of bedside nurses in acute trusts in the Midlands region of England in IVOS in their organizations and describe their views regarding how to improve IVOS.

METHODS

An anonymous self-administered mixed-methods online survey was developed and distributed to nursing staff in acute trusts via antimicrobial stewardship networks between March and May 2023. Quantitative data was analysed to describe participant demographics and behaviours, whereas barriers and enablers to IVOS were explored through thematic content analysis of responses to open-ended questions.

FINDINGS

A total of 545 nursing staff responded to the survey. The majority (65.3%) routinely suggested IVOS to clinicians, despite only 50.6% being aware of local IVOS policies. One-third (34.7%) did not suggest IVOS, relying on doctors, believing their patients needed IV treatment, or lacked knowledge and skills to request IVOS. Content analysis of suggestions for improving the rate of IVOS proposed three major themes (People, Process, System) and identified that education and training, improved confidence and interprofessional relationships, and prompts were important drivers.

CONCLUSION

Nursing staff suggest IVOS to other clinicians, but more education and resources are needed to enable and empower them in this role.

Knowledge, Attitudes, and Practices toward Antimicrobial Resistance among Young Italian Nurses and Students: A Multicenter, Cross-Sectional Study

Background: Nurses play a pivotal role in combating antimicrobial resistance (AMR). However, the success of local and national AMR containment efforts hinges on the knowledge, attitude, and practice (KAP) of nursing staff and undergraduate students. Objectives: This study aims to explore the determinants of nurses' KAP regarding AMR, offering insights to control the emergence and spread of drug-resistant pathogens. Methods: This cross-sectional, multicenter survey involving Italian nurses, nursing students, and healthcare professionals was conducted administering an anonymous online questionnaire focusing on AMR. The median score of 12 was taken as the cutoff for "good KAP." The association between study variables and good KAP was assessed using chi-square or t-tests, followed by multivariable logistic regression analysis for statistically significant (p < 0.05) variables. Findings: Among 848 participants, 61.9% (n = 525) were students, and 39.6% (n = 336) scored as having "low KAP." High KAP was associated with being female and studying AMR independently. Conversely, living in southern Italy and receiving AMR training from pharmaceutical companies were associated with low KAP. Conclusions: Among Italian nurses, AMR awareness relies on those who have studied AMR as self-taught and is affected by gender and region. Italian universities lack in lectures on AMR management, and much needs to be done to improve awareness of antimicrobial stewardship among nonmedical health workers.

Overview of the Participation of Nurses in Antimicrobial Stewardship Activities

Antibiotic resistance is a planetary threat demanding maximum attention from health and social care services worldwide due to the clinical, economic, and human costs. Interventions to address resistance-antimicrobial stewardship (AMS) programs-are multipronged and require the close collaboration of all health care workers involved in antimicrobial decisions and use. Nurses have traditionally been absent from such engagement. This Commentary highlights existing evidence of the need for, and impact of, nursing involvement and leadership in AMS. In addition, four barriers (ie, foundational, ownership, education, and leadership) to the increased involvement of nurses in AMS are discussed, with implications and potential solutions.

Knowledge, Attitude, and Practice About Antibiotic Use and Antimicrobial Resistance Among Nursing Students in China: A Cross Sectional Study

Purpose

The knowledge, attitude, and practices (KAP) concerning antibiotics by healthcare students have the potential impact on controlling antibiotic abuse and antimicrobial resistance (AMR) growth. This study aims to evaluate the levels and explore the associated factors with KAP on antibiotic use and AMR in Chinese nursing students.

Methods

A cross-sectional survey using a self-administered questionnaire consisting of demographics and selected features and KAP on antibiotic use and AMR was conducted to measure KAP levels among nursing students at various universities in Hubei Province, China. The logistic regression analyses were performed to analyze the potential factors associated with the KAP.

Results

The survey eventually included a total of 1959 nursing students. The mean scores for KAP were 57.89 ±26.32, 55.00 ±12.50, and 71.88 ±15.63, respectively. Regarding knowledge, 54.3% of participants were unaware that antibiotic was ineffective against viral infections. Regarding attitude, 36% of participants agreed that current antibiotic abuse existed; 96.2% of participants thought it necessary to set up a special course on antibiotics. Regarding practice, only 48.4% of participants usually purchased antibiotics with a prescription. Multivariable analyses indicated that lack of discussion on AMR in school courses was an independent risk factor against KAP, respectively. The main knowledge sources of antibiotic being outside the classroom was an independent risk factor related to knowledge and practice. The average score >80 points was an independent protective factor related to knowledge and practice.

Conclusion

The KAP level on antibiotic use and AMR among Hubei nursing students was general and required further strengthening. Nursing students with risk factors should be prioritized in educational interventions. The findings of our study pointed out some directions for tailored interventions to improve the training on antibiotics.

Knowledge and perception of antimicrobial resistance and antimicrobial stewardship among healthcare students in Nigeria

Background

Assessment of knowledge and perception of healthcare students regarding antimicrobial resistance (AMR) and antimicrobial stewardship (AMS) would facilitate more effective education of these future prescribers.

Objectives

To assess knowledge and perception of AMR and AMS among healthcare students in Nigerian universities.

Methods

This was a questionnaire-based, cross-sectional survey of medical, nursing and pharmacy undergraduate students from November 2019 to January 2020, using both paper and electronic modes of self-administration.

Results

A total of 335 students participated in the survey. Mean age of respondents was 23±3 years; 114 (34.4%) were in their 5th year of study. Most (78.9%) of the respondents agreed that widespread use of antimicrobials promotes AMR. Only 70 (21.1%) were aware that poor hand hygiene promotes AMR; 45.9% (42.7%, 37.3% and 57.7% for medicine, nursing and pharmacy respectively, p = 0.007) agreed that AMR is promoted by substandard quality of antimicrobials. Majority (94.3%) perceived AMR as a worldwide problem. Over half (60.8%) were not familiar with the term 'antimicrobial stewardship'. Eleven (3.3%) and 122 (36.9%) rated their AMS knowledge as 'very good' and 'poor' respectively.

Conclusions

Nigerian healthcare students had suboptimal knowledge of AMR and AMS. Current undergraduate healthcare curriculum should be reviewed to incorporate AMS principles.

Knowledge, Attitudes, and Practices of Bedside Nurses regarding Antimicrobial Stewardship in China: An Explanatory Sequential Mixed Methods Study

Aim

To evaluate the knowledge, attitudes, and practices of Chinese bedside nurses regarding antimicrobial stewardship, as well as to identify factors that influence nurses' engagement in antimicrobial stewardship.

Background

Antimicrobial resistance is a pressing global health threat. Antimicrobial stewardship is crucial in combating this issue. Nurses play a key role in implementing antimicrobial stewardship. However, little is known about the involvement of Chinese nurses in antimicrobial stewardship.

Methods

An explanatory sequential mixed-methods design was employed. A self-developed questionnaire was administered between March and August 2021 (N = 463), followed by semi-structured interviews with 17 nurses between March and July 2022. Descriptive statistics and qualitative content analysis were used to analyze the data.

Results

The study found that nurses scored 75% in knowledge, 82.8% in attitude, and 84.1% in practice domains. There was a moderate correlation between nurses' knowledge, attitudes, and practices. It revealed that knowing local antimicrobial stewardship programmes information and the frequency of receiving antimicrobial stewardship training had a significant impact on nurses' knowledge scores. The willingness to participate in related training influenced nurses' attitude scores. Being a clinical teacher and the frequency of receiving related training influenced nurses' practice scores. The qualitative phase identified three themes: insufficient knowledge of nurses' engagement, diverse attitudes towards engagement, and limited scopes and absence of standards in nurses' participation.

Conclusions

Our findings emphasize the importance of enhancing nurses' perception and involvement in antimicrobial stewardship. While nurses exhibit positive attitudes and practices, addressing the existing knowledge gap is crucial. To achieve this, it is necessary to clarify the role and responsibilities of nurses in antimicrobial stewardship, provide regular training and innovative methods, strengthen communication and collaboration, and foster a positive work environment. Additionally, actively promoting the development of guidelines and evaluation criteria will enable nurses to more effectively participate. Implications for Nursing Management. Regular training of nurses in antimicrobial stewardship needs to be enhanced. Nursing managers should strive to create positive, empowering, and supportive work environments, participate in policy formulation and implementation, and provide clear expectations for nurses' engagement in antimicrobial stewardship.

Ten golden rules for optimal antibiotic use in hospital settings: the WARNING call to action

Antibiotics are recognized widely for their benefits when used appropriately. However, they are often used inappropriately despite the importance of responsible use within good clinical practice. Effective antibiotic treatment is an essential component of universal healthcare, and it is a global responsibility to ensure appropriate use. Currently, pharmaceutical companies have little incentive to develop new antibiotics due to scientific, regulatory, and financial barriers, further emphasizing the importance of appropriate antibiotic use. To address this issue, the Global Alliance for Infections in Surgery established an international multidisciplinary task force of 295 experts from 115 countries with different backgrounds. The task force developed a position statement called WARNING (Worldwide Antimicrobial Resistance National/International Network Group) aimed at raising awareness of antimicrobial resistance and improving antibiotic prescribing practices worldwide. The statement outlined is 10 axioms, or "golden rules," for the appropriate use of antibiotics that all healthcare workers should consistently adhere in clinical practice.

What are the nursing competencies related to antimicrobial stewardship and how they have been assessed? Results from an integrative rapid review

BACKGROUND

Antimicrobial resistance issues, and the consequent demand for antimicrobial stewardship (AMS) programs, need to be investigated urgently and clearly. Considering the large amount of time nurses spend at patients' bedside, the aim of the present study was to examine recent literature on nursing competency in AMS.

METHODS

Drawing from Tricco and colleagues' seven-stage process, a rapid review was performed. MEDLINE, CINAHL and EMBASE databased were searched from December 1st, 2019 until December 31st, 2021. Article screening and study selection were conducted independently by three reviewers. Data were analyzed narratively and categorized adopting an inductive thematic coding.

RESULTS

Sixteen studies met the inclusion criteria and were included. Publications were mainly authored in USA (n = 4), Australia and New Zealand (n = 4) and Asia (n = 4), followed by Europe (n = 2) and Africa (n = 2). Ten studies were quantitative in design, followed by qualitative (n = 4) and mixed-methods studies (n = 2). Nursing competency in AMS seems to be influenced by a two-dimensional model: on the one hand, internal factors which consisted in knowledge, attitudes and practices and, on the other hand, external aspects which are at environmental level in terms of structures and processes.

CONCLUSION

This study provided a map of dimensions for researchers and practitioners to consider when planning clinical governance, educational activities, and research programs. Significant opportunities exist for nurses to contribute to practice, education, research, and policy efforts aimed at reducing antimicrobial resistance.

Nurses' perceptions of their role in antimicrobial stewardship within the hospital environment. An integrative literature review

BACKGROUND

Antimicrobial stewardship (AMS) has traditionally been the domain of doctors and pharmacists but there is a growing recognition that successful stewardship incorporates a multidisciplinary approach that includes nursing staff. This literature review explores nurses' perceptions of their role in antimicrobial stewardship within the hospital environment and provides new insights to inform future practice.

METHODOLOGY

An integrative literature review was undertaken. Five academic databases were searched, which identified six relevant studies. Whittemore and Knafl's method for conducting an integrative review was followed. ENTREQ guidelines have been adhered to.

FINDINGS

Two themes were identified: nurses' working in partnership with other professionals and engagement in education.

DISCUSSION

Antimicrobial stewardship illustrates the role of the nurse within the wider multidisciplinary team regarding wider patient safety issues and the need for education to enhance this role.

RELEVANCE TO CLINICAL PRACTICE

Nurses have a clear role to play in antimicrobial stewardship but need to be fully cognisant of the issues involved. Further clarity on how nurses should enact this role in their complex working environments is required. It is essential that both student and qualified nurses are able to speak up in order to maximise patient safety, fulfil their professional duty and promote the overall effectiveness of AMS if they witness poor antibiotic management practices.

Antibiotic Stewardship Attitudes and Beliefs Among Frontline Staff Nurses: Impact of Virtual Education

Background: Nurses are vital healthcare team members and are often underutilised in antimicrobial stewardship (AS) activities. Several nursing responsibilities, such as taking allergy history and obtaining cultures, already overlap with AS activities. Nurses can play a crucial role in promoting AS in resource-limited settings. This study was conducted to assess frontline staff nurses’ baseline attitudes and beliefs towards AS, and see if a virtual education campaign consisting of newsletters and tip sheets would affect those attitudes and beliefs. Methods: An online survey (pre-survey) was conducted of all in-patient nurses employed in the authors’ hospital on their attitudes and beliefs regarding AS. The survey consisted of 24 questions divided into three domains: demographic and practice information, nursing roles, and beliefs and attitudes towards AS programmes (ASP). After obtaining the results of the pre-survey, the authors started distributing monthly newsletters on various AS topics via email and posting them on a resource page. Topics included how to obtain an accurate allergy history, how to use microbiology results to help guide decisions, and stop therapy in cases of colonisation. The authors also distributed the same survey as a follow-up 6-month survey (post-survey) in March 2021 to gauge the impact of their virtual education efforts. Results: In total, 109 nurses working in the adult in-patient setting of the authors’ institution completed the pre-survey in September 2020, and 64 nurses completed the post-survey in March 2021. Overall, most nurses had a positive attitude towards AS tasks, and over 90% of those who responded in the pre-survey and post-survey agreed with the statement that nurses are antibiotic stewards, thought it was important or very important to obtain appropriate cultures, and understood the relationship between Clostridioides difficile and antibiotics. Most pre-survey respondents listed knowledge gaps in microbiology (47 out of 64 [86%]) and antibiotics (53 out of 64 [84%]) as well as scope of practice concerns (48 out of 64 [75%]) as barriers to nurse participation. The virtual education helped raise the familiarity with the ASP and more nurses in the post-survey said they were familiar with the stewardship programme compared with the pre-survey (48.4% versus 23.2%; p=0.001). Conclusions: This study showed that most nurses consider themselves antibiotic stewards and want to participate in AS activities; however, barriers to nursing involvement, such as lack of knowledge, scope of practice concerns, and time constraints, persist. Virtual education may be an option to increase nursing awareness and participation on ASPs in resource-limited settings.

Beyond consumption: a qualitative investigation of hospital clinician attitudes to receiving feedback on antimicrobial prescribing quality

BACKGROUND

Feedback on optimal antimicrobial prescribing to clinicians is an important strategy to ensure antimicrobial stewardship (AMS) in the hospital setting.

OBJECTIVE

To explore the perceptions of antimicrobial prescribing feedback among clinicians in acute care.

STUDY DESIGN

Prospective qualitative design.

SETTING

A large inner-city tertiary referral center in Dublin, Ireland.

PARTICIPANTS

Clinicians were recruited from the hospital clinician population.

METHODS

A qualitative study was conducted with a purposive sample of multidisciplinary clinicians. Focus groups and semistructured interviews were used to collect data that were analyzed inductively to identify themes.

RESULTS

In total, 30 clinicians from medical, surgical, nursing and pharmacy professions participated in the study. We identified 5 themes: (1) antimicrobial consumption perceived as a proxy measure for prescribing quality; (2) lack of connection between antimicrobial prescribing and patient outcomes; (3) relevance and impact of antimicrobial prescribing feedback associated with professional role; (4) attitudes regarding feedback as an AMS strategy; and (5) knowledge regarding AMS, including antimicrobial prescribing quality measures.

CONCLUSIONS

Focused feedback on antimicrobial prescribing, with clear goals for improvement, could serve as a useful AMS strategy among clinicians in the acute-care setting. The need for further education and training in AMS was also identified.

A novel framework to guide antibiotic stewardship nursing practice

BACKGROUND

There is a pervasive view among some nurses and health care disciplines that antibiotic stewardship (AS) is solely a physician or pharmacist responsibility. There is an urgent need to alter this view so that nurses can seize every opportunity to prevent patient harm from antibiotics and optimize antibiotic use. One challenge to achieving full nurse engagement as equal members of the AS team is lack of an organizing framework to illustrate relationships of phenomena and concepts inherent to adoption of AS nursing practices.

METHODS

We sought to create a framework derived from the peer-reviewed literature, systematic and scoping reviews, and professional standards, consensus statements and white papers. The emerging framework went through multiple iterations as it was vetted with nurse clinicians, scholars and educators, physicians, pharmacists, infection preventionists and AS subject matter experts.

RESULTS

Our evidence-based Antibiotic Stewardship Nursing Practice SCAN-P Framework provides the much-needed context and clarity to help guide local-level nurses to participate in and lead AS nursing practice.

CONCLUSIONS

Nurses worldwide are ideally situated to provide holistic person-centered care, advocate for judicious use of antibiotics to minimize antibiotic resistance, and be AS educators of their patients, communities and the general public. The Antibiotic Stewardship Nursing Practice SCAN-P Framework provides a tool to do so.

What does antimicrobial stewardship look like where you are? Global narratives from participants in a massive open online course

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.

Optimising antimicrobial use in humans - review of current evidence and an interdisciplinary consensus on key priorities for research

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.

Investigating infection management and antimicrobial stewardship in surgery: a qualitative study from India and South Africa

OBJECTIVES

To investigate the drivers for infection management and antimicrobial stewardship (AMS) across high-infection-risk surgical pathways.

METHODS

A qualitative study-ethnographic observation of clinical practices, patient case studies, and face-to-face interviews with healthcare professionals (HCPs) and patients-was conducted across cardiovascular and thoracic and gastrointestinal surgical pathways in South Africa (SA) and India. Aided by Nvivo 11 software, data were coded and analysed until saturation was reached. The multiple modes of enquiry enabled cross-validation and triangulation of findings.

RESULTS

Between July 2018 and August 2019, data were gathered from 190 hours of non-participant observations (138 India, 72 SA), interviews with HCPs (44 India, 61 SA), patients (six India, eight SA), and case studies (four India, two SA). Across the surgical pathway, multiple barriers impede effective infection management and AMS. The existing implicit roles of HCPs (including nurses and senior surgeons) are overlooked as interventions target junior doctors, bypassing the opportunity for integrating infection-related care across the surgical team. Critically, the ownership of decisions remains with the operating surgeons, and entrenched hierarchies restrict the inclusion of other HCPs in decision-making. The structural foundations to enable staff to change their behaviours and participate in infection-related surgical care are lacking.

CONCLUSIONS

Identifying the implicit existing HCP roles in infection management is critical and will facilitate the development of effective and transparent processes across the surgical team for optimized care. Applying a framework approach that includes nurse leadership, empowering pharmacists and engaging surgical leads, is essential for integrated AMS and infection-related care.

Nurse role and contribution to antimicrobial stewardship: An integrative review

AIM

To examine existing published literature regarding nurses and antimicrobial stewardship, and their potential role and contribution, to identify what is known, to evaluate methodologies used in published research, and to review and integrate findings to inform practice and future priorities for research.

DESIGN

Integrative review.

METHODOLOGY

The approach to this review was informed by Whittemore and Knafl's integrative review methodology. Electronic databases were searched for papers published since the start of the database to November 2019, with abstracts available, related to humans and published in English. Papers were included regardless of practice setting (acute, aged, and primary care) and if they were research based, included nurses as participants and reported specifically on results from nurses or that had implications for nursing practice. Excluded were conference abstracts, and papers focussed solely on nurse prescriber, nurse practitioner, or nurse manager roles.

RESULTS

Fifty-two papers were included in the review. Identified themes were: i) nursing knowledge, learning needs and education; ii) nurse perceptions of the nursing role and motivations for involvement; iii) nursing brokerage and influence on information flow to and from patients; iv) nursing workflow, workload and workarounds; and v) nurse leadership. Methodological quality of the included papers varied, limiting transferability and applicability of findings for some of the included studies.

CONCLUSION

Formal inclusion of nurses in antimicrobial stewardship activities has been associated with improved nurse knowledge, nurse confidence, and in some cases improved clinical outcomes for patients. The review reinforces nursing values as a motivator of nursing actions, and reveals the complex yet significant influence of nurses on antimicrobial prescribing. Potential opportunities to enhance nurses' participation and contribution to antimicrobial stewardship include; formal acknowledgement of the nurse role, educating nurses so that they are aware of how they can contribute, collaborating with nurses in planning and implementing local stewardship activities, and ensuring nurse leaders are involved. However, evidence on this topic remains limited. Research is needed to facilitate greater understanding about the nature, scope and influence of the nurse role in antimicrobial stewardship, how nurses enact and carry out their role, and nurses' support needs. Tweetable abstract: Integrative review explores #nurse role in #antimicrobialstewardship. Nurse contribution, influence significant, but not well understood.

Interventions to improve the review of antibiotic therapy in acute care hospitals: a systematic review and narrative synthesis

Objectives

To synthesize current evidence for the effectiveness of interventions to ensure the timely review of antibiotics in acute care hospitals.

Methods

Five databases were searched from 1 January 2015 to 8 March 2019 for studies in English, focused on the timely review of antibiotics in acute care hospitals. Randomized controlled trials, non-randomized studies, case–control and cohort study designs were eligible. Intervention strategies were categorized according to the Cochrane Effective Practice and Organisation of Care taxonomy of health interventions, then mapped to the intervention functions of the behaviour change wheel.

Results

Fourteen studies were included. Most studies (11 out of 14) were conducted in single sites. Nine out of 14 reported intervention delivery by more than one healthcare professional. Physicians were the main targets of interventions in all studies. Thirteen out of 14 studies tested interventions comprising more than one strategy. The three most commonly utilized strategies within interventions were clinical practice guidelines, audit and feedback, and educational materials. Only one study employed theory in intervention evaluation. Reported interventions led to timely review and switch of IV antibiotic therapy, and shortened durations of overall antibiotic therapy.

Conclusions

Interventions to improve the review of antibiotics were found to be effective in the short to medium term, with limited evidence of long-term sustainability in multiple sites. Future research may benefit from the application of theory to intervention design and detailed specifications of interventions to aid their easy replication and implementation in different contexts.

Mapping hospital antimicrobial stewardship programmes in the Gulf Cooperation Council states against international standards: a systematic review

BACKGROUND

While there is evidence of implementation of antimicrobial stewardship programmes (ASPs) in the Gulf Cooperation Council (GCC) states, there has been limited benchmarking and mapping to international standards and frameworks.

AIM

To critically appraise and synthesize the evidence of ASP implementation in GCC hospitals with reference to the framework of the Centers for Disease Control and Prevention (CDC), identifying key facilitators and barriers.

METHODS

A systematic review protocol was developed based on Preferred Reporting Items for Systematic Reviews and Meta-analyses for Protocols guidelines. Five electronic databases were searched for studies published in English from 2010 onwards. Study selection, quality assessment and data extraction were performed independently by two reviewers. A narrative synthesis was conducted with ASP interventions mapped to CDC core elements.

FINDINGS

Seventeen studies were identified, most of which (N=11) were from Saudi Arabia. Mapping to the CDC framework identified key areas of strengths and weaknesses in reporting implementation. Studies more commonly reported core elements of pharmacy expertise, selected aspects of implementation actions, tracking, antibiotic use and resistance, and education. Little emphasis was placed on the reporting of leadership and accountability. Key implementation facilitators were physician and organization support, information systems and education, and barriers were dedicated staff, workload and funding.

CONCLUSION

There is a need to enhance the reporting of ASP implementation in GCC hospitals. The CDC framework should be used as a guide during the development, implementation and reporting of ASP interventions. Action is required to identify facilitators and overcome barriers, where possible.

Empowerment of nurses in antibiotic stewardship: a social ecological qualitative analysis

BACKGROUND

Inappropriate antibiotics use and antimicrobial resistance (AMR) are increasingly becoming global health issues of great concern. Despite the established antibiotic stewardship programmes (ASPs) in many countries, limited efforts have been made to engage nurses and clearly define their roles in ASPs.

AIM

An exploratory qualitative study was conducted to understand the facilitators and barriers that impact nurses' involvement and empowerment in antibiotic stewardship.

METHODS

Focus group discussions (FGDs) were conducted with purposively sampled nurses from three major public hospitals in Singapore. FGDs were audio-recorded and transcribed verbatim. Data were analysed using Applied Thematic Analysis and interpreted using the Social Ecological Model.

FINDINGS

At the intrapersonal level, nurses felt empowered in carrying out their roles in antibiotic administration. They saw themselves as gatekeepers to ensure that the prescribed antibiotics were administered appropriately. However, nurses felt they lacked the knowledge and expertise in antibiotic use and AMR prevention. At the interpersonal level, this deficit in knowledge and expertise in antibiotic use impacted how they were perceived by patients and caregivers as well as their interactions with the primary care team when voicing outpatient safety concerns and antibiotic administration suggestions. At the organizational level, nurses relied on drug administration guidelines to ensure appropriate antibiotic administration and as a safety net when physicians questioned their clinical practice. At the community level, nurses felt there was a lack of awareness and knowledge on antibiotic use among the general population.

CONCLUSION

These findings provide important insights to harness the contributions of nurses, and to formally acknowledge and enlarge their roles in ASPs.