Exploring general practitioners' perception of the value of natural history information and their awareness and use of guidelines' resources to support antibiotic prescribing for self-limiting infections: a qualitative study in Australian general practice.

BACKGROUND: The newest version of the Therapeutic Guidelines' antibiotic chapter introduced patient- and clinician-facing resources to support decision-making about antibiotic use for self-limiting infections. It is unclear whether general practitioners (GPs) are aware of and use these resources, including the natural history information they contain. We explored GPs' perceptions of the value and their use of natural history information, and their use of the Therapeutic Guidelines' resources (summary table, discussion boxes, decision aids) to support antibiotic decision-making. METHODS: Semi-structured interviews with 21 Australian GPs were conducted. Interviews were recorded, transcribed and thematically analysed by two independent researchers. RESULTS: Four themes emerged: (1) GPs perceive natural history information as valuable in consultations for self-limiting conditions and use it for a range of purposes, but desire specific information for infectious and non-infectious conditions; (2) GPs' reasons for using patient-facing resources were manifold, including managing patients' expectations for antibiotics, legitimising the decision not to provide antibiotics and as a prescription substitute; (3) the guidelines are a useful and important educational resource, but typically not consulted at the time of deciding whether to prescribe antibiotics; and (4) experience and attitude towards shared decision-making and looking up information during consultations influenced whether GPs involved patients in decision-making and used a decision aid. CONCLUSIONS: GPs perceived natural history information to be valuable in discussions about antibiotic use for self-limiting conditions. Patient and clinician resources were generally perceived as useful, although reasons for use varied, and a few barriers to use were reported.

Information about the natural history of acute infections commonly seen in primary care: a systematic review of clinical practice guidelines.

BACKGROUND: Many of the acute infections that are seen in primary care and sometimes managed with antibiotics are self-resolving and antibiotics may be unnecessary. Information about the natural history of these infections underpins antibiotic stewardship strategies such as delayed prescribing and shared decision making, yet whether it's reported in guidelines is unknown. We examined, in clinical guidelines, the reporting of natural history information and relevant antibiotic stewardship strategies for acute infections commonly seen in primary care. METHODS: A systematic review of national and international guidelines (2010 onwards), available electronically, for managing acute infections (respiratory, urinary, or skin and soft tissue). We searched MEDLINE, CINAHL, EMBASE, TRIP, and GIN databases and websites of 22 guideline-publishing organisations. RESULTS: We identified 82 guidelines, covering 114 eligible infections. Natural history information was reported in 49 (59.8%) of the guidelines and 66 (57.9%) of the reported conditions, most commonly for respiratory tract infections. Quantitative information about the expected infection duration was provided for 63.5% (n = 42) of the infections. Delayed antibiotic prescribing strategy was recommended for 34.2% (n = 39) of them and shared decision making for 21% (n = 24). CONCLUSIONS: Just over half of the guidelines for acute infections that are commonly managed in primary care and sometimes with antibiotics contained natural history information. As many of these infections spontaneously improve, this is a missed opportunity to disseminate this information to clinicians, promote antibiotic stewardship, and facilitate conversations with patients and informed decision making. Systematic review registration CRD42021247048.

Development and Implementation of an Antimicrobial Stewardship Checklist in Sub-Saharan Africa: A Co-Creation Consensus Approach.

Antimicrobial stewardship (AMS) initiatives promote the responsible use of antimicrobials in healthcare settings as a key measure to curb the global threat of antimicrobial resistance (AMR). Defining the core elements of AMS is essential for developing and evaluating comprehensive AMS programmes. This project used co-creation and Delphi consensus procedures to adapt and extend the existing published international AMS checklist. The overall objective was to arrive at a contextualised checklist of core AMS elements and key behaviours for use within healthcare settings in Sub-Saharan Africa, as well as to implement the checklist in health institutions in four African countries. The AMS checklist tool was developed using a modified Delphi approach to achieve local expert consensus on the items to be included on the checklist. Fourteen healthcare/public health professionals from Tanzania, Zambia, Uganda, Ghana and the UK were invited to review, score and comment on items from a published global AMS checklist. Following their feedback, 8 items were rephrased, and 25 new items were added to the checklist. The final AMS checklist tool was deployed across 19 healthcare sites and used to assess AMS programmes before and after an AMS intervention in 14 of the 19 sites. The final tool comprised 54 items. Across the 14 sites, the completed checklists consistently showed improvements for all the AMS components following the intervention. The greatest improvements observed were the presence of formal multidisciplinary AMS structures (79%) and the execution of a point-prevalence survey (72%). The elements with the least improvement were access to laboratory/imaging services (7%) and the presence of adequate financial support for AMS (14%). In addition to capturing the quantitative and qualitative changes associated with the AMS intervention, project evaluation suggested that administering the AMS checklist made unique contributions to ongoing AMS activities. Furthermore, 29 additional AMS activities were reported as a direct result of the prompting checklist questions. Contextualised, co-created AMS tools are necessary for managing antimicrobial use across healthcare settings and increasing local AMS ownership and commitment. This study led to the development of a new AMS checklist, which proved successful in capturing AMS improvements in Tanzania, Zambia, Uganda, and Ghana. The tool also made unique contributions to furthering local AMS efforts. This study extends the existing AMS materials for low- and middle-income countries and provides empirical evidence for successful use in practice.