Determinants of antibiotic prescribing in primary care in Vietnam: a qualitative study using the Theoretical Domains Framework.

BACKGROUND: To formulate effective strategies for antimicrobial stewardship (AMS) in primary care, it is crucial to gain a thorough understanding of factors influencing prescribers' behavior within the context. This qualitative study utilizes the Theoretical Domains Framework (TDF) to uncover these influential factors. METHODS: We conducted a qualitative study using in-depth interviews and focus group discussions with primary care workers in two provinces in rural Vietnam. Data analysis employed a combined inductive and deductive approach, with the deductive aspect grounded in the TDF. RESULTS: Thirty-eight doctors, doctor associates, and pharmacists participated in twenty-two interviews and two focus group discussions. We identified sixteen themes, directly mapping onto seven TDF domains: knowledge, skills, behavioral regulation, environmental context and resources, social influences, social/professional role and identity, and optimism. Factors driving unnecessary prescription of antibiotics include low awareness of antimicrobial resistance (AMR), diagnostic uncertainty, prescription-based reimbursement policy, inadequate medication supplies, insufficient financing, patients' perception of health insurance medication as an entitlement, and maintaining doctor-patient relationships. Potential factors facilitating AMS activities include time availability for in-person patient consultation, experience in health communication, and willingness to take action against AMR. CONCLUSION: Utilizing the TDF to systematically analyze and present behavioral determinants offers a structured foundation for designing impactful AMS interventions in primary care. The findings underscore the importance of not only enhancing knowledge and skills but also implementing environmental restructuring, regulation, and enablement measures to effectively tackle unnecessary antibiotic prescribing in this context.

[Antibiotic antimicrobial stewardship rounds is an effective tool in geriatric clinics]. / Antibiotikaronder inom geriatriska verksamheter.

The antibiotic stewardship round (ASR) is a way to use the knowledge of the infectious disease (ID) specialist to audit and assess the treatment with antibiotics and promote rational use. We implemented ASRs twice a week in two geriatric hospitals and weekly in advanced home care facilities during 9 weeks. All patients treated with antibiotics were discussed and advice regarding the antibiotic treatment was given. In 25 percent of the cases the ID specialist found that the ASR made a difference to the treatment plan, and in 10,8 percent of cases the antibiotic treatment could be discontinued. Other common advice was to switch from intravenous to oral administration and shorten the number of treatment days. Thus, ASRs were found to be an intervention associated with lower and more rational antibiotic use and should be considered an important tool for antimicrobial stewardship in geriatric hospitals.

"What if the patient has a severe reaction, and it is my fault?" A qualitative study exploring factors for sustainable implementation of penicillin allergy delabelling.

BACKGROUND: Penicillin allergy delabelling (PAD), the process of evaluating penicillin allergy labels, is a key target in antibiotic stewardship, but uptake of the procedure outside clinical studies is limited. We aimed to explore factors that need to be addressed to sustainably implement a clinical pathway for PAD. METHODS: We conducted a qualitative study based on semi-structured interviews with focus groups consisting of a purposive sample of twenty-five nurses and physicians working in four different hospitals in Western Norway. Systematic text condensation was applied for analysis. RESULTS: Psychological safety was reported as crucial for clinicians to perform PAD. A narrative of uncertainty and anticipated negative outcomes were negatively associated with PAD performance. Education, guidelines, and colleague- and leadership support could together create psychological safety and empower health personnel to perform PAD. Key factors for sustainable implementation of PAD were facilitating the informant's profound motivation for providing optimal health care and for reducing antimicrobial resistance. Informants were motivated by the prospect of a simplified PAD procedure. We identified three main needs for implementation of PAD: (1) creating psychological safety; (2) utilising clinicians' inherent motivation and (3) optimal organisational structures. CONCLUSION: A planned implementation of PAD must acknowledge clinicians' need for psychological safety and aid reassurance through training, leadership, and guidelines. To implement PAD as an everyday practice it must be minimally disruptive and provide a contextually adaptive logistic chain. Also, the clinician's motivation for providing the best possible healthcare should be utilised to aid implementation. The results of this study will aid sustainable implementation of PAD in Norway. ETHICS: The study was approved by the Western Norway Regional Committee for Medical Research Ethics (Study No:199210).

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.

Impact of the COVID-19 pandemic on antibiotic utilization in a tertiary hospital.

INTRODUCTION: This study aimed to determine the use of antimicrobial drugs during the second year of the coronavirus disease 2019 (COVID-19) pandemic, and evaluate the pandemic`s impact on antibiotic use by comparing with the pre-pandemic period. METHODOLOGY: The study was a retrospective point prevalence study. Patients aged ≥ 18 years, who received antibiotics in our hospital between 11 February 2020. and 3 January 2022 were evaluated. The antibiotics were categorized according to the 2021 Access/Watch/Reserve (AWARe) classification. Compliance with recommendations from infectious diseases (ID) physicians, and reasons for inappropriate treatment were evaluated. RESULTS: Among the hospitalized patients, 323 (36.4%) during the pre-pandemic days (PPD), and 361 (50.1%) during pandemic days (PD), used at least one antimicrobial drug (p < 0.001). The most frequently used antibiotics during PPD and PD were piperacillin, tazobactam, and imipenem/meropenem. The use of the "Access" group antibiotics decreased in the PD, while the use of the "Watch" and "Reserve" groups increased (p = 0.034). There was 100% (n = 209) compliance with ID consultation in the PPD, and 91.9% (n = 227) in the PD (p < 0.001). In the PPD, 64 (19.8%). of the treatments received by inpatients were inappropriate, and during the PD 100 (27.7%) were inappropriate (p = 0.016). CONCLUSIONS: The pandemic led to an increase in the overuse and inappropriate use of antimicrobial drugs, particularly in the Watch and Reserve groups, in both COVID-19 and non-COVID-19 clinics. There was a notable transition towards the increased utilization of broad-spectrum antibiotics during the pandemic.

Prescriber-level surveillance of outpatient antimicrobial consumption to enable targeted antimicrobial stewardship: a nationwide observational study, Switzerland, 2015 to 2022.

BackgroundIn Europe and other high-income countries, antibiotics are mainly prescribed in the outpatient setting, which consists of primary, specialist and hospital-affiliated outpatient care. Established surveillance platforms report antimicrobial consumption (AMC) on aggregated levels and the contribution of the different prescriber groups is unknown.AimTo determine the contribution of different prescribers to the overall outpatient AMC in Switzerland.MethodsWe conducted a retrospective observational study using claims data from one large Swiss health insurance company, covering the period from 2015 to 2022. We analysed antibiotic prescriptions (ATC code J01) prescribed in the Swiss outpatient setting. Results were reported as defined daily doses per 1,000 inhabitants per day (DID) and weighted according to the total population of Switzerland based on census data.ResultsWe analysed 3,663,590 antibiotic prescriptions from 49 prescriber groups. Overall, AMC ranged from 9.12 DID (2015) to 7.99 DID (2022). General internal medicine (40.1% of all prescribed DID in 2022), hospital-affiliated outpatient care (20.6%), group practices (17.3%), paediatrics (5.4%) and gynaecology (3.7%) were the largest prescriber groups. Primary care accounted for two-thirds of the prescribed DID. Quantity and type of antibiotics prescribed varied between the prescriber groups. Broad-spectrum penicillins, tetracyclines and macrolides were the most prescribed antibiotic classes.ConclusionPrimary care contributed considerably less to AMC than anticipated, and hospital-affiliated outpatient care emerged as an important prescriber. Surveillance at the prescriber level enables the identification of prescribing patterns within all prescriber groups, offering unprecedented visibility and allowing a more targeted antibiotic stewardship according to prescriber groups.

Improving Antibiotic Use in Nursing Homes by Infection Prevention and Control and Antibiotic Stewardship (IMAGINE): Protocol for a Before-and-After Intervention and Implementation Study.

BACKGROUND: Despite the extensive use of antibiotics and the growing challenge of antimicrobial resistance, there has been a lack of substantial initiatives aimed at diminishing the prevalence of infections in nursing homes and enhancing the detection of urinary tract infections (UTIs). OBJECTIVE: This study aims to systematize and enhance efforts to prevent health care-associated infections, mainly UTIs and reduce antibiotic inappropriateness by implementing a multifaceted intervention targeting health care professionals in nursing homes. METHODS: A before-and-after intervention study carried out in a minimum of 10 nursing homes in each of the 8 European participating countries (Denmark, Greece, Hungary, Lithuania, Poland, Slovakia, Slovenia, and Spain). A team of 4 professionals consisting of nurses, doctors, health care assistants, or health care helpers are actively involved in each nursing home. Over the initial 3-month period, professionals in each nursing home are registering information on UTIs as well as infection and prevention control measures by means of the Audit Project Odense method. The audit will be repeated after implementing a multifaceted intervention. The intervention will consist of feedback and discussion of the results from the first registration, training on the implementation of infection and prevention control techniques provided by experts, appropriateness of the diagnostic approach and antibiotic prescribing for UTIs, and provision of information materials on infection control and antimicrobial stewardship targeted to staff, residents, and relatives. We will compare the pre- and postintervention audit results using chi-square test for prescription appropriateness and Student t test for implemented hygiene elements. RESULTS: A total of 109 nursing homes have participated in the pilot study and the first registration audit. The results of the first audit registration are expected to be published in autumn of 2024. The final results will be published by the end of 2025. CONCLUSIONS: This is a European Union-funded project aimed at contributing to the battle against antimicrobial resistance through improvement of the quality of management of common infections based on evidence-based interventions tailored to the nursing home setting and a diverse range of professionals. We expect the intervention to result in a significant increase in the number of hygiene activities implemented by health care providers and residents. Additionally, we anticipate a marked reduction in the number of inappropriately managed UTIs, as well as a substantial decrease in the overall incidence of infections following the intervention. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/60099.

Appropriateness of antibiotic prescribing in paediatrics: retrospective controlled study assessing a multifaceted intervention in Northern Italy in a 7-year period.

BACKGROUND: Academic detailing, audit and feedback, and peer comparison have been advocated as effective ways to promote appropriateness of prescribing and antimicrobial stewardship (AMS). This study explored the effectiveness of a multifaceted intervention aimed at supporting the appropriateness of antibiotic prescribing in paediatrics. METHODS: Over the course of 7 years, all 89 paediatricians of the Local Health Authority (LHA) of Reggio Emilia (530 000 residents) were provided with scientific literature focused on antimicrobial resistance and the appropriateness of use of specific antibiotics, together with local data on antimicrobial resistance and prescribing reports comparing each paediatrician with colleagues in the same district and with local averages. Prescribing rates of specific target antibiotics/classes of antibiotics were evaluated by comparing Reggio-Emilia with the other seven LHAs of the Emilia-Romagna Region (control area), adjusting for prescriptions during a 2-year baseline period. RESULTS: A significant increase in the rate of amoxicillin prescriptions (91 more per 1000 children/year) was observed in the intervention area compared with the control area along with a significant reduction in the rate of amoxicillin+clavulanate prescriptions (70 fewer per 1000 children/year) and a significant increase in the ratio of their prescription rates. No differences were observed in cephalosporin and macrolide prescription rates and overall antibiotic prescriptions. CONCLUSIONS: Improvements in prescribing appropriateness were observed. This study confirms the importance of an audit and feedback approach through small group meetings supported by scientific literature, local resistance data and prescribing reports. Such approach should always be considered as part of multifaceted interventions to promote AMS.

Evaluating the impact of rapid antimicrobial susceptibility testing for bloodstream infections: a review of actionability, antibiotic use and patient outcome metrics.

Antimicrobial susceptibility testing (AST) is a core function of the clinical microbiology laboratory and is critical to the management of patients with bloodstream infections (BSIs) to facilitate optimal antibiotic therapy selection. Recent technological advances have resulted in several rapid methods for determining susceptibility direct from positive blood culture that can provide turnaround times in under 8 h, which is considerably shorter than conventional culture-based methods. As diagnostic results do not directly produce a medical intervention, actionability is a primary determinant of the effect these technologies have on antibiotic use and ultimately patient outcomes. Randomized controlled trials and observational studies consistently show that rapid AST significantly reduces time to results and improves antimicrobial therapy for patients with BSI across various methods, patient populations and organisms. To date, the clinical impact of rapid AST has been demonstrated in some observational studies, but randomized controlled trials have not been sufficiently powered to validate many of these findings. This article reviews various metrics that have been described in the literature to measure the impact of rapid AST on actionability, antibiotic exposure and patient outcomes, as well as highlighting how implementation and workflow processes can affect these metrics.

Lack of Knowledge of Antibiotic Risks Contributes to Primary Care Patients' Expectations of Antibiotics for Common Symptoms.

Patient expectations of receiving antibiotics for common symptoms can trigger unnecessary use. We conducted a survey (n = 564) between January 2020 to June 2021 in public and private primary care clinics in Texas to study the prevalence and predictors of patients' antibiotic expectations for common symptoms/illnesses. We surveyed Black patients (33%) and Hispanic/Latine patients (47%), and over 93% expected to receive an antibiotic for at least 1 of the 5 pre-defined symptoms/illnesses. Public clinic patients were nearly twice as likely to expect antibiotics for sore throat, diarrhea, and cold/flu than private clinic patients. Lack of knowledge of potential risks of antibiotic use was associated with increased antibiotic expectations for diarrhea (odds ratio [OR] = 1.6; 95% CI, 1.1-2.4) and cold/flu symptoms (OR = 2.9; 95% CI, 2.0-4.4). Lower education and inadequate health literacy were predictors of antibiotic expectations for diarrhea. Future antibiotic stewardship interventions should tailor patient education materials to include information on antibiotic risks and guidance on appropriate antibiotic indications.

"Antimicrobial utilization in a paediatric intensive care unit in India: A step towards strengthening antimicrobial stewardship practices".

Antimicrobials are frequently used in critically ill children admitted to the Paediatric Intensive Care Unit (PICU). The antimicrobial use data from Indian PICUs is limited using standard metrics such as Days of therapy (DOT). This study aimed to determine the baseline trend of antimicrobial use in PICU of a tertiary care teaching hospital of Raipur district of Chhattisgarh, India using standard metrics with the goal of developing facility-wide antibiotic policy and strengthening the antimicrobial stewardship activities. This active surveillance was conducted over a period of 18 months, from November 1, 2019, to March 21, 2021, in patients aged one month to 14 years who were admitted for ≥ 48 hours to the PICU at a tertiary care teaching hospital of Raipur District. Data on patient characteristics, antimicrobial indications, antimicrobial prescription information, and clinical outcomes were collected using pre-designed data abstraction forms. The descriptive statistic was used to represent the results. The antimicrobial consumption was analyzed according to the WHO AWaRe Class (Access, Watch, and Reserve groups) of antibiotics. The antimicrobial consumption was expressed as DOT/1000 patient-days (PD). A total of 216 patients were surveyed during the study period. The average number of antimicrobials prescribed per hospitalisation was 2.60 (range: 1-12), with 97.22% administered via parenteral route. Overall, DOT/1000-PD was 1318. The consumption of Watch Group antimicrobials was highest with 949 DOT/1000-PD, followed by Access (215) and Reserve Group (154), respectively. Ceftriaxone (208 DOT/1000 PD) was the most commonly prescribed antimicrobial agent, followed by Vancomycin (201), Meropenem (175), Piperacillin-Tazobactam (122) and Colistin (91). The patients who were escalated (28.24%) from empirical antimicrobial therapy had longer median PICU stay (8 days) compared those who were de-escalated (23.6%). Targeted therapy was given in 10.2% patients. The overall mortality rate was 14.35% and was higher (29.3%) in patients in whom empirical therapy was escalated compared to those who were de-escalated or continued. The study established a benchmark for antimicrobials use in the PICU and highlighted priority areas for antimicrobial stewardship intervention to enhance de-escalation rates, enhance targeted therapy, and reduce the overuse of antimicrobials especially belonging to the reserve group.

Surveillance of antimicrobial utilization in Africa: a systematic review and meta-analysis of prescription rates, indications, and quality of use from point prevalence surveys.

BACKGROUND: Antimicrobial resistance (AMR) is a global public health concern that is fueled by the overuse of antimicrobial agents. Low- and middle-income countries, including those in Africa,. Point prevalence surveys (PPS) have been recognized as valuable tools for assessing antimicrobial utilization and guiding quality improvement initiatives. This systematic review and meta-analysis aimed to evaluate the prescription rates, indications, and quality of antimicrobial use in African health facilities. METHODS: A comprehensive search was conducted in multiple databases, including PubMed, Scopus, Embase, Hinari (Research4Life) and Google Scholar. Studies reporting the point prevalence of antimicrobial prescription or use in healthcare settings using validated PPS tools were included. The quality of the studies was assessed using the Joanna Briggs Institute (JBI) critical appraisal checklist. A random-effects meta-analysis was conducted to combine the estimates. Heterogeneity was evaluated using Q statistics, I² statistics, meta-regression, and sensitivity analysis. Publication bias was assessed using a funnel plot and Egger's regression test, with a p-value of < 0.05 indicating the presence of bias. RESULTS: Out of 1790 potential studies identified, 32 articles were included in the meta-analysis. The pooled prescription rate in acute care hospitals was 60%, with significant heterogeneity (I2 = 99%, p < 0.001). Therapeutic prescriptions constituted 62% of all the prescribed antimicrobials. Prescription quality varied: documentation of reasons in notes was 64%, targeted therapy was 10%, and parenteral prescriptions were 65%, with guideline compliance at 48%. Hospital-acquired infections comprised 20% of all prescriptions. Subgroup analyses revealed regional disparities in antimicrobial prescription prevalence, with Western Africa showing a prevalence of 65% and 44% in Southern Africa. Publication bias adjustment estimated the prescription rate at 54.8%, with sensitivity analysis confirming minor variances among studies. CONCLUSION: This systematic review and meta-analysis provide valuable insights into antimicrobial utilization in African health facilities. The findings highlight the need for improved antimicrobial stewardship and infection control programs to address the high prevalence of irrational antimicrobial prescribing. The study emphasizes the importance of conducting regular surveillance through PPS to gather reliable data on antimicrobial usage, inform policy development, and monitor the effectiveness of interventions aimed at mitigating AMR.

Getting rapid diagnostic test data into the appropriate hands by leveraging pharmacy staff and a clinical surveillance platform: a case study from a US community hospital.

OBJECTIVES: To outline the procedural implementation and optimization of rapid diagnostic test (RDT) results for bloodstream infections (BSIs) and to evaluate the combination of RDTs with real-time antimicrobial stewardship team (AST) support plus clinical surveillance platform (CSP) software on time to appropriate therapy in BSIs at a single health system. METHODS: Blood culture reporting and communication were reported for four time periods: (i) a pre-BCID [BioFire® FilmArray® Blood Culture Identification (BCID) Panel] implementation period that consisted of literature review and blood culture notification procedure revision; (ii) a BCID implementation period that consisted of BCID implementation, real-time results notification via CSP, and creation of a treatment algorithm; (iii) a post-BCID implementation period; and (iv) a BCID2 implementation period. Time to appropriate therapy metrics was reported for the BCID2 time period. RESULTS: The mean time from BCID2 result to administration of effective antibiotics was 1.2 h (range 0-7.9 h) and time to optimal therapy was 7.6 h (range 0-113.8 h) during the BCID2 Panel implementation period. When comparing time to optimal antibiotic administration among patients growing ceftriaxone-resistant Enterobacterales, the BCID2 Panel group (mean 2.8 h) was significantly faster than the post-BCID Panel group (17.7 h; P = 0.0041). CONCLUSIONS: Challenges exist in communicating results to the appropriate personnel on the healthcare team who have the knowledge to act on these data and prescribe targeted therapy against the pathogen(s) identified. In this report, we outline the procedures for telephonic communication and CSP support that were implemented at our health system to distribute RDT data to individuals capable of assessing results, enabling timely optimization of antimicrobial therapy.

Infection prevention and control: critical strategies for nursing practice.

Infection prevention and control (IPC) is essential in nursing practice to safeguard patient health and reduce healthcare-associated infections. This article explores IPC strategies, including hand hygiene, the use of personal protective equipment, environmental cleaning, safe injection practices, and antimicrobial stewardship. It discusses the implementation challenges and solutions, such as ensuring compliance through education, monitoring and strong leadership. IPC measures are crucial in preventing infections such as catheter-associated urinary tract infections, central line-associated bloodstream infections, surgical site infections, and ventilator-associated pneumonia. By integrating personalised IPC strategies into nursing practice, healthcare providers can significantly improve infection control outcomes and enhance overall patient safety and quality of care.

A Systems Thinking Approach to Tackle Antimicrobial Resistance.

Antimicrobial resistance (AMR) poses a significant global health threat. Due to its complexity, holistic approaches focusing on the interconnected factors influencing AMR across One Health domains are necessary. This study adopts system dynamics with extensive stakeholder engagement to unravel feedback processes between factors driving AMR. Initial results indicate numerous feedback loops between AMR drivers, which are not restricted to healthcare settings alone. A simulation model will be built to test various One Health scenarios to support decision-making on mitigating AMR.