Patient-related determinants of antibiotic use: a systematic review

Objectives

We aimed to assess patient-related determinants potentially influencing antibiotic use.

Understanding what helps or hinders asthma action plan use: a systematic review and synthesis of the qualitative literature

Objective

To understand better what helps and/or hinders asthma action plan use from the professionals and patients/carers perspective.

Methods

Systematic review and qualitative synthesis (using meta-ethnography).

Results

Nineteen studies (20 papers) were included in an analysis of patients/carers’ and professionals’ views. Seven main influences on action plan implementation were identified including perceived un-helpfulness and irrelevance of the plans. Translation and synthesis of the original authors’ interpretations suggested that action plan promotion and use was influenced by professional and patient/carers’ asthma beliefs and attitudes and patient/carer experiences of managing asthma. Action plan use is hindered because professionals and patients/carers have different explanatory models of asthma, its management and their respective roles in the management process. Patients/carers, based on their experiential knowledge of their condition, perceive themselves as capable, effective in managing their asthma, but health professionals do not always share this view.

Conclusion

Professionally provided medically focused action plans that do not ‘fit’ with and incorporate the patients’/carers’ views of asthma, and their management strategies, will continue to be under-utilised.

Practice implications

Professionals need to develop a more patient-centred, partnership-based, approach to the joint development and review of action plans, recognising the experiential asthma knowledge of patients/carers.     

GPs' views in five European countries of interventions to promote prudent antibiotic use

Background

A variety of interventions have been developed to promote a more prudent use of antibiotics by implementing clinical guidelines. It is not yet clear which are most acceptable and feasible for implementation across a wide range of contexts. Previous research has been confined mainly to examining views of individual interventions in a national context.

Aim

To explore GPs'' views and experiences of strategies to promote a more prudent use of antibiotics, across five countries.

Design and setting

Qualitative study using thematic and framework analysis in general practices in Belgium, France, Poland, Spain, and the UK.

Method

Fifty-two semi-structured interviews explored GPs'' views and experiences of strategies aimed at promoting a more prudent use of antibiotics. Interviews were carried out in person or over the telephone, transcribed verbatim, and translated into English where necessary for analysis.

Results

Themes were remarkably consistent across the countries. GPs had a preference for interventions that allowed discussion and comparison with local colleagues, which helped them to identify how their practice could improve. Other popular components of interventions included the use of near-patient tests to reduce diagnostic uncertainty, and the involvement of other health professionals to increase their responsibility for prescribing.

Conclusion

The study findings could be used to inform future interventions to improve their acceptability to GPs. Consistency in views across countries indicates the potential for development of an intervention that could be implemented on a European scale.     

Barriers and facilitators to discussing HPV with head and neck cancer patients: A qualitative study using the theoretical domains framework

ObjectiveThe incidence of human papillomavirus-associated head and neck cancers (HPV-HNC) is increasing worldwide. Research in other clinical contexts has shown that healthcare professionals (HCPs) can find discussing HPV with patients challenging. However, limited research has been conducted in HNC. This study aimed to investigate barriers and facilitators to, discussing HPV among HCPs caring for patients with HNC in Ireland.MethodsSemi-structured telephone/face-to-face interviews were conducted with HCPs. Barriers and facilitators to discussing HPV with patients were identified using the Theoretical Domains Framework (TDF).Results20 HCPs (8 clinicians, 3 nurses, 9 allied healthcare professionals) were interviewed. Barriers to discussing HPV included professionals' lack of HPV knowledge, difficulties in talking about sexual issues with patients and lack of privacy to discuss HPV in busy clinic settings. Facilitators included increasing public and patient awareness of the link between HPV and HNC and professional education and skills development.ConclusionsThis is the first theoretically informed study to identify barriers and facilitators to discussing HPV with HNC patients. HCPs consider HPV discussions to be an essential part of HNC patient care.Practice implicationsUnderstanding the issues associated with patient-provider HPV communication will help develop effective interventions to support HCPs in their HPV discussions.     

Perceived barriers and facilitators to antiretroviral therapy adherence among youth aged 15–24 years at a regional HIV clinic in SouthWestern Uganda: a qualitative study

IntroductionSouth-Western region has the second highest HIV prevalence in Uganda. Youth aged 15–24 have shown poor adherence to antiretroviral therapy compared to the older cohorts. Previous studies from other regions have shown various barriers and facilitators. Our study was designed to describe specific barriers and facilitators to treatment adherence among youths in a large regional HIV clinic in southwestern Uganda.MethodsWe used a phenomenological qualitative study design conducted amongst 30 purposively selected HIV positive youth aged 15–24 years enrolled at Mbarara Regional Referral Hospital HIV clinic on ART for a period of at least one year and 6 key informants using in-depth interviews. The data was collected in an inductive manner during the period between 21st July and 17th August 2020. The recordings were backed up, transcribed verbatim and then analyzed manually using thematic content analysis.ResultsThe barriers to ART adherence were described in three descending categories as perceived treatment burden, perceived resultant stigma and discrimination, whereas the main facilitators were; perceived usefulness of HIV medications, availability of free services and Social supportConclusionYouths aged 15–24 have challenges with ART associated treatment burden and fear to disclose their HIV status because of the resultant stigma from their communities. Many have however accepted the fact that HIV medications are lifesaving and are strongly motivated to adhere to their medications despite the circumstances.     

Surveillance of antibiotic use in hospitals: methods, trends and targets

A standardised antibiotic surveillance system is an essential requirement of all antibiotic control strategies. Antibiotic use can be quantified accurately using patient-level surveillance, although this is not feasible for most hospitals. Instead, population-level surveillance is a more realistic alternative for ongoing and systematic monitoring of antibiotic use. Monitoring of aggregate, ward-supply data on a monthly basis, stratification by patient care area, and analysis by the anatomical therapeutic chemical/defined daily dose (ATC/DDD) system, adjusting for bed-occupancy, provides a clear picture of antibiotic consumption density and time-trends within a hospital. When usage rates are supplemented and interpreted according to changes in hospital resource indicators, benchmarking is facilitated. This provides an efficient tool for triggering and targeting antibiotic control interventions.     

Difficulties in Balint groups: a qualitative study of leaders' experiences

Background

Balint groups (BGs) are a means of enhancing competence in the physician–patient relationship and are also regarded as beneficial for GPs'' mental health. However, voluntary BGs are still few, some members terminate their participation, and problems are reported in obligatory groups in residency programmes. This raises questions about possible negative aspects of BGs.

Aim

To examine difficulties in BGs as experienced by BG leaders.

Design of study

Qualitative study using interviews.

Setting

Eight BG leaders from five countries were interviewed.

Method

The interviews focused on the informants'' experiences of difficulties in their groups and were analysed with a systematic text-condensation method.

Results

Three categories of difficulties emerged from the analysis: 1) the individual physician having needs, vulnerabilities, and defences; 2) the group (including the leader) having problems of hidden agendas, rivalries, and frames; and 3) the surrounding environment defining the conditions of the group. BGs were found to fit into modern theories of small groups as complex systems. They are submitted to group dynamics that are sometimes malicious, and are exposed to often tough environmental conditions.

Conclusion

Professionally conducted BGs seem to be a gentle, efficient method to train physicians, but with limitations. Participation of a member demands psychological stability and an open mind. BGs need support from the leadership of healthcare organisations in order to exist.     

Reducing antibiotic use in influenza: challenges and rewards.

Respiratory tract infections are a frequent cause of medical consultations. Although the majority of such infections are viral in aetiology, they account for three-quarters of all antibiotic consumption, since bacterial infections of the upper and lower respiratory tract, notably bronchitis, sinusitis and pneumonia, are the most frequent complications resulting from virus infections, especially influenza in adults and children. The resulting widespread use of antibiotics is a primary factor that drives the emergence of antibiotic resistance at both the local and regional levels. Recent surveys suggest that the proportion of patients with influenza-like illness who receive antibiotics is at least double the actual incidence of the infections for which the treatment is intended. Inappropriate prescribing needs to be tackled by encouraging more rigorous diagnosis, prevention and treatment of viral infections, specifically influenza. Although accurate diagnosis of influenza is challenging, rapid tests to identify the causative pathogen, e.g., RT-PCR tests for influenza viruses, are becoming more reliable and affordable. The use of antiviral drugs, particularly neuraminidase inhibitors, is a specific and effective way of preventing and treating influenza, and has been shown to reduce the incidence of complications and associated antibiotic use. In contrast to bacterial resistance to antibiotics, viral resistance to neuraminidase inhibitors is low, and their high specificity means that they cannot exert selection pressure on any other species. The widespread adoption of these principles may have a significant effect on antimicrobial use and resistance.     

Combined audit of hospital antibiotic use and a prevalence survey of healthcare-associated infection

Appropriate antibiotic use improves patient outcome and prevents the emergence of antibiotic resistance. A point-prevalence audit of antibiotic use at Beaumont Hospital, Dublin was carried out during the collection of data for the 2006 Hospital Infection Society (HIS) Prevalence Survey of Healthcare-Associated Infection. All inpatients who met the HIS survey entry criteria were included in the HIS survey, and all inpatients who were receiving antibiotics at the time of the survey were included in the point-prevalence audit of antibiotic use. Among these, 7.18% and 36.8% of patients had a healthcare-associated infection (HCAI) and were on antibiotics, respectively. Unnecessary collection of duplicate data was avoided by conducting an audit of antibiotic use and a national survey of HCAI simultaneously.     

Timing of antibiotic administration and outcomes of hospitalized patients with community-acquired and healthcare-associated pneumonia

The effects of antibiotic timing on outcomes of patients with community-acquired pneumonia (CAP) are controversial. Moreover, no information is available regarding this issue in healthcare-associated pneumonia (HCAP). We aimed to determine the impact of antibiotic timing on 30-day mortality of patients with CAP and HCAP. Non-immunocompromised adults admitted to hospital through the emergency department (ED) with community-onset pneumonia were prospectively observed from 2001 to 2009. Patients who received prior antibiotics were excluded. Of 1593 patients with pneumonia who were analyzed, 1274 had CAP and 319 HCAP. The mean time from patient arrival at the ED until antibiotic administration was 5.8 h (standard deviation (SD) 3.5) in CAP and 6.1 h (SD 3.8) in HCAP (p 0.30). Mortality was higher in patients with HCAP (5.5% vs. 13.5%; p <0.001). After adjusting for confounding factors in a logistic regression analysis, the antibiotic administration ≤4 h was not associated with decreased 30-day mortality in patients with CAP (odds ratio (OR) 1.12, 95% confidence interval (CI) 0.57–2.21) and in patients with HCAP (OR 0.59, 95% CI 0.19–1.83). Similarly, antibiotic administration ≤8 h was not associated with decreased 30-day mortality in CAP (OR 1.58, 95% CI 0.64–3.88) and HCAP patients (OR 0.59, 95% CI 0.19–1.83). In conclusion, antibiotic administration within 4 or 8 h of arrival at the ED did not improve 30-day survival in hospitalized adults for CAP or HCAP.     

Evaluation of antibiotic use in Pediatric Intensive Care Unit of a developing country

Background:Pediatric Intensive Care Unit (PICU) patients are often prescribed antibiotics with a low threshold in comparison to patients elsewhere. Irrational antibiotics use can lead to rapid emergence of drug resistance, so surveillance of their use is important.Objectives:To evaluate the use of antibiotics in relation to bacteriological findings in PICU of a Tertiary Hospital.Methods:Retrospective review of medical records of all children (age 1 month–16 years) admitted in our closed multidisciplinary-cardiothoracic PICU from January to June 2013 was performed, after approval from Ethical Review Committee. For each antibiotic, indication (prophylactic, empiric, therapeutic) and duration of use were recorded. All diagnoses of infections were recorded according to diagnostic criteria of IPSCC 2005. Results are presented as frequency and percentages and median with inter quartile range using SPSS version 19.Results:All of the total 240 patients admitted in PICU during the study period received antibiotics: 43% (n = 104) prophylactically, 42% (n = 102) empirically, and 15% (n = 15) therapeutically. Median number of antibiotic use per patient in PICU was 3, with range of 1–7. 25% received 1 antibiotic, 23% received 2 antibiotics, 29% received 3 antibiotics, and rest received ≥4 antibiotics. Most commonly used antibiotics were cefazolin, meropenem, vancomycin and ceftriaxone, and most frequently used combination was meropenem and vancomycin. In majority of the cases, (70%) empiric antibiotic combinations were stopped in 72 h.Conclusion:This is the first report of antibiotics use in PICU from our country, which shows that antibiotics are prescribed universally in our PICU. Strategies to assess the need for antibiotic use are needed.     

The effect of preoperative oral antibiotic use on the risk of periprosthetic joint infection after primary knee or hip replacement: a retrospective study with a 1-year follow-up

ObjectivesAntibiotics are used for various reasons before elective joint replacement surgery. The aim of this study was to investigate patients' use of oral antibiotics before joint replacement surgery and how this affects the risk for periprosthetic joint infection (PJI).MethodsPatients having a primary hip or knee replacement in a tertiary care hospital between September 2002 and December 2013 were identified (n = 23 171). Information on oral antibiotic courses purchased 90 days preoperatively and patients' chronic diseases was gathered. Patients with a PJI in a 1-year follow-up period were identified. The association between antibiotic use and PJI was examined using a multivariable logistic regression model and propensity score matching.ResultsOne hundred and fifty-eight (0.68%) cases of PJI were identified. In total, 4106 (18%) joint replacement operations were preceded by at least one course of antibiotics. The incidence of PJI for patients with preoperative use of oral antibiotics was 0.29% (12/4106), whereas for patients without antibiotic use it was 0.77% (146/19 065). A preoperative antibiotic course was associated with a reduced risk for subsequent PJI in the multivariable model (OR 0.40, 95% CI 0.22–0.73). Similar results were found in the propensity score matched material (OR 0.34, 95% CI 0.18–0.65).ConclusionsThe use of oral antibiotics before elective joint replacement surgery is common and has a potential effect on the subsequent risk for PJI. Nevertheless, indiscriminate use of antibiotics before elective joint replacement surgery cannot be recommended, even though treatment of active infections remains an important way to prevent surgical site infections.     

Primary antibiotic resistance of Helicobacter pylori in Chinese patients: a multiregion prospective 7-year study

ObjectivesTo explore the characteristics of Helicobacter pylori resistance in China and the association between antibiotic resistance and several clinical factors.MethodsH. pylori strains were collected from patients in 13 provinces or cities in China between 2010 and 2016. Demographic data including type of disease, geographic area, age, gender and isolation year were collected to analyse their association with antibiotic resistance. Antibiotic resistance was detected using the Etest test and the Kirby-Bauer disc diffusion method.ResultsH. pylori were successfully cultured from 1117 patients. The prevalence of metronidazole, clarithromycin (CLA), azithromycin, levofloxacin (LEV), moxifloxacin, amoxicillin (AMO), tetracycline and rifampicin resistance was 78.2, 22.1, 23.3, 19.2, 17.2, 3.4, 1.9 and 1.5%, respectively. No resistance to furazolidone was observed. The resistance rates to LEV and moxifloxacin were higher in strains isolated from patients with gastritis compared to those with duodenal ulcer and among women. Compared to patients ≥40 years old, younger patients exhibited lower resistance rates to CLA, azithromycin, LEV and moxifloxacin. The resistance rates to CLA and AMO were higher in strains isolated more recently, and we also found that the prevalence of resistance to metronidazole, CLA, azithromycin and AMO were significantly different among different regions of China.ConclusionsThe resistance rates to metronidazole, CLA and LEV were high in China. Patient age, gender, disease and location were associated with the resistance of H. pylori to some antibiotics. Furazolidone, AMO and tetracycline are better choices for H. pylori treatment in China.     

New elements for informed decision making: a qualitative study of older adults' views

Objective

To explore older adults’ views of existing informed decision making (IDM) elements and investigate the need for additional elements.

Methods

We recruited persons 65 and older to participate in six focus groups. Participants completed questionnaires about IDM preferences, and discussed videotapes of idealized patient–physician interactions in light of seven IDM elements: (1) discussion of the patient's role in decision making; (2) discussion of the clinical issue; (3) discussion of alternatives; (4) discussion of benefits/risks; (5) discussion of uncertainties; (6) assessment of patient understanding; and (7) exploration of patient preference. We used a modified grounded theory approach to assess agreement with existing IDM elements and identify new elements.

Results

In questionnaires, 97–100% of 59 participants rated each IDM element as “somewhat” or “very” important. Qualitative analysis supported existing elements and suggested two more: opportunity for input from trusted others, and discussion of decisions’ impacts on patients’ daily lives. Elements overlapped with global communication themes.

Conclusion

Focus groups affirmed existing IDM elements and suggested two more with particular relevance for older patients.

Practice implications

Incorporation of additional IDM elements into clinical practice can enhance informed participation of older adults in decision making.     

Exploring medication use to seek concordance with ''non-adherent'' patients: a qualitative study.

BACKGROUND: 'Concordance' has been proposed as a new approach towards sub-optimal medication use; however, it is not clear how this may be achieved in practice. AIM: To develop a strategy for understanding sub-optimal medication use and seek concordance during primary care consultations. DESIGN: A developmental qualitative study using a modified action research design. SETTING: Three Scottish general practices. METHOD: Patients using treatment sub-optimally and having poor clinical control were offered extended consultations to explore their situation. Their authority to make treatment decisions was made explicit throughout. Clinicians refined a consultation model during ten 'Balint-style' meetings that ran in parallel with the analysis. The analysis included all material from the consultations, meetings, and discussion with patients after the intervention. RESULTS: Three practitioners recorded 59 consultations with 24 adult patients. A six-stage process was developed, first to understand and then to discuss existing medication use. Understanding of medication use was best established using a structured exploration of patients' beliefs about their illness and medication. Four problematic issues were identified: understanding, acceptance, level of personal control, and motivation. Pragmatic interventions were developed that were tailored to the issues identified. Of the 22 subjects usefully engaged in the process, 14 had improved clinical control or medication use three months after intervention ceased. CONCLUSIONS: A sensitive, structured exploration of patients' beliefs can elucidate useful insights that explain medication use and expose barriers to change. Identifying and discussing these barriers improved management for some. A model to assist such concordant prescribing is presented.