Dataset Information

How Can National Antimicrobial Stewardship Interventions in Primary Care Be Improved? A Stakeholder Consultation.

ABSTRACT: Many antimicrobial stewardship (AMS) interventions have been implemented in England, facilitating decreases in antibiotic prescribing. Nevertheless, there is substantial variation in antibiotic prescribing across England and some healthcare organizations remain high prescribers of antibiotics. This study aimed to identify ways to improve AMS interventions to further optimize antibiotic prescribing in primary care in England. Stakeholders representing different primary care settings were invited to, and 15 participated in, a focus group or telephone interview to identify ways to improve existing AMS interventions. Forty-five intervention suggestions were generated and 31 were prioritized for inclusion in an online survey. Fifteen stakeholders completed the survey appraising each proposed intervention using the pre-defined APEASE (i.e., Affordability, Practicability, Effectiveness, Acceptability, Safety, and Equity) criteria. The highest-rated nine interventions were prioritized as most promising and feasible, including: quality improvement, multidisciplinary peer learning, appointing AMS leads, auditing individual-level prescribing, developing tools for prescribing audits, improving inductions for new prescribers, ensuring consistent local approaches to antibiotic prescribing, providing online AMS training to all patient-facing staff, and increasing staff time available for AMS work with standardizing AMS-related roles. These prioritized interventions could be incorporated into existing national interventions or developed as stand-alone interventions to help further optimize antibiotic prescribing in primary care in England.

SUBMITTER: Borek AJ

PROVIDER: S-EPMC6963414 | biostudies-literature | 2019 Oct

REPOSITORIES: biostudies-literature

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How Can National Antimicrobial Stewardship Interventions in Primary Care Be Improved? A Stakeholder Consultation.

Borek Aleksandra J AJ Wanat Marta M Sallis Anna A Ashiru-Oredope Diane D Atkins Lou L Beech Elizabeth E Hopkins Susan S Jones Leah L McNulty Cliodna C Shaw Karen K Taborn Esther E Butler Christopher C Chadborn Tim T Tonkin-Crine Sarah S

Antibiotics (Basel, Switzerland) 20191031 4

Many antimicrobial stewardship (AMS) interventions have been implemented in England, facilitating decreases in antibiotic prescribing. Nevertheless, there is substantial variation in antibiotic prescribing across England and some healthcare organizations remain high prescribers of antibiotics. This study aimed to identify ways to improve AMS interventions to further optimize antibiotic prescribing in primary care in England. Stakeholders representing different primary care settings were invited ...[more]

PMID: 31683590

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Project description:A major modifiable factor contributing to antimicrobial resistance (AMR) is inappropriate use and overuse of antimicrobials, such as antibiotics. This study aimed to describe the content and mechanism of action of antimicrobial stewardship (AMS) interventions to improve appropriate antibiotic use for respiratory tract infections (RTI) in primary and community care. This study also aimed to describe who these interventions were aimed at and the specific behaviors targeted for change. Evidence-based guidelines, peer-review publications, and infection experts were consulted to identify behaviors relevant to AMS for RTI in primary care and interventions to target these behaviors. Behavior change tools were used to describe the content of interventions. Theoretical frameworks were used to describe mechanisms of action. A total of 32 behaviors targeting six different groups were identified (patients; prescribers; community pharmacists; providers; commissioners; providers and commissioners). Thirty-nine interventions targeting the behaviors were identified (patients = 15, prescribers = 22, community pharmacy staff = 8, providers = 18, and commissioners = 18). Interventions targeted a mean of 5.8 behaviors (range 1-27). Influences on behavior most frequently targeted by interventions were psychological capability (knowledge and skills); reflective motivation (beliefs about consequences, intentions, social/professional role and identity); and physical opportunity (environmental context and resources). Interventions were most commonly characterized as achieving change by training, enabling, or educating and were delivered mainly through guidelines, service provision, and communications & marketing. Interventions included a mean of four Behavior Change Techniques (BCTs) (range 1-14). We identified little intervention content targeting automatic motivation and social opportunity influences on behavior. The majority of interventions focussed on education and training, which target knowledge and skills though the provision of instructions on how to perform a behavior and information about health consequences. Interventions could be refined with the inclusion of relevant BCTs, such as goal-setting and action planning (identified in only a few interventions), to translate instruction on how to perform a behavior into action. This study provides a platform to refine content and plan evaluation of antimicrobial stewardship interventions.

Project description:ObjectiveWhile various interventions have helped reduce antibiotic prescribing, further gains can be made. This study aimed to identify ways to optimise antimicrobial stewardship (AMS) interventions by assessing the extent to which important influences on antibiotic prescribing are addressed (or not) by behavioural content of AMS interventions.SettingsEnglish primary care.InterventionsAMS interventions targeting healthcare professionals' antibiotic prescribing for respiratory tract infections.MethodsWe conducted two rapid reviews. The first included qualitative studies with healthcare professionals on self-reported influences on antibiotic prescribing. The influences were inductively coded and categorised using the Theoretical Domains Framework (TDF). Prespecified criteria were used to identify key TDF domains. The second review included studies of AMS interventions. Data on effectiveness were extracted. Components of effective interventions were extracted and coded using the TDF, Behaviour Change Wheel and Behaviour Change Techniques (BCTs) taxonomy. Using prespecified matrices, we assessed the extent to which BCTs and intervention functions addressed the key TDF domains of influences on prescribing.ResultsWe identified 13 qualitative studies, 41 types of influences on antibiotic prescribing and 6 key TDF domains of influences: 'beliefs about consequences', 'social influences', 'skills', 'environmental context and resources', 'intentions' and 'emotions'. We identified 17 research-tested AMS interventions; nine of them effective and four nationally implemented. Interventions addressed all six key TDF domains of influences. Four of these six key TDF domains were addressed by 50%-67% BCTs that were theoretically congruent with these domains, whereas TDF domain 'skills' was addressed by 24% of congruent BCTs and 'emotions' by none.ConclusionsFurther improvement of antibiotic prescribing could be facilitated by: (1) national implementation of effective research-tested AMS interventions (eg, electronic decision support tools, training in interactive use of leaflets, point-of-care testing); (2) targeting important, less-addressed TDF domains (eg, 'skills', 'emotions'); (3) using relevant, under-used BCTs to target key TDF domains (eg, 'forming/reversing habits', 'reducing negative emotions', 'social support'). These could be incorporated into existing, or developed as new, AMS interventions.

Project description:BackgroundAntimicrobial resistance is an emerging problem worldwide and poses a significant threat to human health. Antimicrobial stewardship programmes are being implemented in health systems globally, primarily in hospitals, to address the growing threat of antimicrobial resistance. Despite the significance of primary health care services in providing health care to communities, antimicrobial stewardship programmes are not well established in this sector, especially in rural and remote settings. This narrative review aims to identify in rural and remote primary health care settings the (1) correlation of antimicrobial resistance with antibiotic prescribing and volume of antibiotic use, (2) appropriateness of antimicrobial prescribing, (3) risk factors associated with inappropriate use/prescribing of antibiotics, and (4) effective antimicrobial stewardship strategies.MethodsThe international literature was searched for English only articles between 2000 and 2020 using specified keywords. Seven electronic databases were searched: Scopus, Cochrane, Embase, CINAHL, PubMed, Ovid Medline and Ovid Emcare. Publication screening and analysis were conducted using Joanna Briggs Institute systematic review tools.ResultsFifty-one eligible articles were identified. Inappropriate and excessive antimicrobial prescribing and use directly led to increases in antimicrobial resistance. Increasing rurality of practice is associated with disproportionally higher rates of inappropriate prescribing compared to those in metropolitan areas. Physician knowledge, attitude and behaviour play important roles in mediating antimicrobial prescribing, with strong intrinsic and extrinsic influences including patient factors. Antimicrobial stewardship strategies in rural and remote primary health care settings focus on health care provider and patient education, clinician support systems, utility of antimicrobial resistance surveillance, and policy changes. Results of these interventions were generally positive with decreased antimicrobial resistance rates and improved appropriateness of antimicrobial prescribing.ConclusionsInappropriate prescribing and excessive use of antimicrobials are an important contributor to the increasing resistance towards antimicrobial agents particularly in rural and remote primary health care. Antimicrobial stewardship programmes in the form of education, clinical support, surveillance, and policies have been mostly successful in reducing prescribing rates and inappropriate prescriptions. The narrative review highlighted the need for longer interventions to assess changes in antimicrobial resistance rates. The review also identified a lack of differentiation between rural and remote contexts and Indigenous health was inadequately addressed. Future research should have a greater focus on effective interventional components and patient perspectives.

Project description:BackgroundAs meropenem is a restricted antimicrobial, lessons learned from its real-life usage will be applicable to antimicrobial stewardship (AMS) more generally.ObjectivesTo retrospectively evaluate meropenem usage at our institution to identify targets for AMS interventions.MethodsPatients receiving meropenem documented with an 'alert antimicrobial' form at two tertiary care UK hospitals were identified retrospectively. Clinical records and microbiology results were reviewed.ResultsA total of 107 adult inpatients receiving meropenem were identified. This was first-line in 47% and escalation therapy in 53%. Source control was required in 28% of cases after escalation, for predictable reasons. Those ultimately requiring source control had received more prior antimicrobial agents than those who did not (P = 0.03). Meropenem was rationalized in 24% of cases (after median 4 days). Positive microbiology enabled rationalization (OR 12.3, 95% CI 2.7-55.5, P = 0.001) but rates of appropriate sampling varied. In cases with positive microbiology where meropenem was not rationalized, continuation was retrospectively considered clinically and microbiologically necessary in 8/40 cases (0/17 empirical first-line usage). Rationalization was more likely when meropenem susceptibility was not released on the microbiology report (OR 5.2, 95% CI 1.3-20.2, P = 0.02). Input from an infection specialist was associated with a reduced duration of meropenem therapy (P < 0.0001). Early review by an infection specialist has the potential to further facilitate rationalization.ConclusionsIn real-life clinical practice, core aspects of infection management remain tractable targets for AMS interventions: microbiological sampling, source control and infection specialist input. Further targets include supporting rationalization to less familiar carbapenem-sparing antimicrobials, restricting first-line meropenem usage and selectively reporting meropenem susceptibility.

Project description:BackgroundMore than 90% of antibiotics are prescribed in primary care, but 50% may be unnecessary. Reducing unnecessary antibiotic overuse is needed to limit antimicrobial resistance. We conducted a pragmatic trial of a primary care provider-focused antimicrobial stewardship intervention to reduce antibiotic prescriptions in primary care.MethodsPrimary care practitioners from six primary care clinics in Toronto, Ontario were assigned to intervention or control groups to evaluate the effectiveness of a multi-faceted intervention for reducing antibiotic prescriptions to adults with respiratory and urinary tract infections. The intervention included provider education, clinical decision aids, and audit and feedback of antibiotic prescribing. The primary outcome was total antibiotic prescriptions for these infections. Secondary outcomes were delayed prescriptions, prescriptions longer than 7 days, recommended antibiotic use, and outcomes for individual infections. Generalized estimating equations were used to estimate treatment effects, adjusting for clustering by clinic and baseline differences.ResultsThere were 1682 encounters involving 54 primary care providers from January until May 31, 2019. In intervention clinics, the odds of any antibiotic prescription was reduced 22% (adjusted Odds Ratio (OR) = 0.78; 95% Confidence Interval (CI) = 0.64.0.96). The odds that a delay in filling a prescription was recommended was increased (adjusted OR=2.29; 95% CI=1.37, 3.83), while prescription durations greater than 7 days were reduced (adjusted OR=0.24; 95% CI=0.13, 0.43). Recommended antibiotic use was similar in control (85.4%) and intervention clinics (91.8%, p=0.37).ConclusionsA community-based, primary care provider-focused antimicrobial stewardship intervention was associated with a reduced likelihood of antibiotic prescriptions for respiratory and urinary infections, an increase in delayed prescriptions, and reduced prescription durations.Trial registrationclinicaltrials.gov ( NCT03517215 ).

Dataset Information

How Can National Antimicrobial Stewardship Interventions in Primary Care Be Improved? A Stakeholder Consultation.

Publications

How Can National Antimicrobial Stewardship Interventions in Primary Care Be Improved? A Stakeholder Consultation.

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