Perceptions,current practices,and interventions of community pharmacists regarding antimicrobial stewardship: A qualitative study

BackgroundCommunity health care accounts for the vast majority of antibiotic use in Europe. Given the threat of antimicrobial resistance (AMR), there is an urgent need to develop new antimicrobial stewardship (AMS) interventions in primary care that could involve different health care providers, including community pharmacists.ObjectivesThis study aimed to explore the perceptions, currents practices, and interventions of community pharmacists regarding AMS.MethodsSemistructured qualitative interviews were conducted with community pharmacists in France. Participants were recruited through a professional organization of community pharmacists combined with a snowballing technique. Interviews were audio recorded, transcribed, and analyzed using thematic analysis. The Consolidated Framework for Implementation Research was used while developing the interview guide and carrying out thematic analysis.ResultsSixteen community pharmacists participated. All the respondents had good awareness about antimicrobial resistance and believed that community pharmacists had an important role in tackling AMR. Some barriers to community pharmacists’ participation in AMS were identified such as difficult interactions with prescribers, lack of time, and lack of access to patient medical records and diagnosis. Increased patient education, audits and feedback of antibiotic prescribing, increased point-of-care testing, and delayed prescribing were interventions suggested by the pharmacists to improve antibiotic use in primary care. Strategies cited by participants to facilitate the implementation of such interventions are increased pharmacist–general practitioner collaboration, specialized training, clinical decision support tools, and financial incentives.ConclusionThis study suggests that community pharmacists could play a greater role in infection management and AMS interventions. Further interprofessional collaboration is needed to optimize antibiotic prescribing and utilization in community health care.     

Analgesic use by ageing and elderly patients with chronic non-malignant pain: a qualitative study

Background Analgesics are used in the management of chronic non-malignant pain (CNMP), a condition which is highly prevalent among older adults. CNMP may not only be physically distressing but also complicated by psychosocial and economic factors. An individual’s perception and use of analgesics may be influenced by a range of factors such as perceptions of risk or benefits, ability to purchase medication or access to non-pharmacological therapies or specialist care. Objective The aim of this study was to describe the perceptions and experiences of analgesics by ageing and elderly individuals with CNMP and identify factors that influence their use. Setting Telephone interviews with 28 members of Chronic Pain Ireland aged ≥50. Method In-depth semi-structured interviews; audio-recorded, transcribed verbatim, and thematically analysed. Main outcome measure Experiences and perceptions of ageing and elderly individuals with CNMP taking analgesics. Results A combination of factors specific to the patient and arising from outside influences informed perceptions and experiences of analgesics. Pain severity, perceived efficacy of analgesics, occurrence of adverse-effects and concerns about addiction/dependence were identified as internal factors influencing medication use. External factors included views of family members, access to specialised care and the individual’s interaction with healthcare professionals (HCPs). Conclusion Individuals with CNMP regard analgesics as an important method for managing pain and are relied upon when other interventions are difficult to access. HCPs in primary care, who are the main point of contact for patients, need to take into account the various factors that may influence analgesic use when consulting with this patient group.

     

A qualitative process evaluation of the introduction of procalcitonin testing as an antimicrobial stewardship intervention

Background Successful antimicrobial stewardship interventions are imperative in today’s environment of antimicrobial resistance. New antimicrobial stewardship interventions should include qualitative analysis such as a process evaluation to determine which elements within an intervention are effective and provide insight into the context in which the intervention is introduced. Objective To assess the implementation process and explore the contextual factors which influenced implementation. Setting An academic teaching hospital in Cork, Ireland. Methods A process evaluation was conducted on completion of a feasibility study of the introduction of a procalcitonin antimicrobial stewardship intervention. The process evaluation consisted of semi-structured face-to-face interviews of key stakeholders including participating (senior) doctors (5), medical laboratory scientists (3) and a hospital administrator. The Consolidated Framework for Implementation Research was used to guide data collection, analysis, and interpretation. Main outcome measures Qualitative assessment of the intervention implementation process, the contextual factors which influenced implementation and identification of improvements to the intervention and its implementation and determine if proceeding to a randomised controlled trial would be appropriate. Results Analysis of the interviews identified three main themes. (1) The procalcitonin intervention and implementation process was viewed positively to support prescribing decisions. Participants identified modifications to procalcitonin processing and availability to improve implementation and allow procalcitonin to be “more of a clinical influence”. (2) In the antimicrobial stewardship context the concept of fear of missing an infection and risks of potentially serious outcomes for patients emerged. (3) The hospital context consisted of barriers such as available resources and facilitators including the hospital culture of quality improvement. Conclusion This process evaluation provides a detailed analysis of the implementation of procalcitonin testing as an antimicrobial stewardship intervention. The positive findings of this process evaluation and feasibility study should be built upon and a full randomised controlled trial and economic evaluation should be conducted in a variety of hospital settings to confirm the effectiveness of procalcitonin as an antimicrobial stewardship intervention.

     

Pharmacists' and physicians' perception of antibiotic policies in New South Wales public hospitals

Background — The potential of antibiotic policies in hospitals to improve antibiotic use depends on the compliance of practitioners with these policies. It is conceivable that the way the policies are perceived by practitioners can influence their compliance. Objective— To determine the perception and awareness of pharmacists and physicians of their current hospital antibiotic policy. Setting — Public hospitals in New South Wales, Australia. Method — Pharmacists and physicians were surveyed using a structured questionnaire seeking the extent of agreement or disagreement with a series of statements about their hospital's antibiotic policy. All hospitals had at least one antibiotic policy. A simple one-stage cluster sample of 241 pharmacists and a two-stage cluster sample of 701 physicians were obtained. Factor analysis was used to identify the dimensions of perception. General linear modelling was used to investigate the effects of predictor variables on outcome variables. Results — The response rates were 91 per cent and 77 per cent for pharmacists and physicians, respectively. The proportion of respondents who were aware of their hospital's antibiotic policy was 86 per cent (190/220) for pharmacists and 61 per cent (332/542) for the physicians. Factor analysis identified three factors related to how practitioners perceived their current hospital's antibiotic policies. These were: the usefulness of antibiotic policies (utility), how the policy was applied in the hospital (application) and the perceived problems associated with the policy (problems). Pharmacists were significantly more likely than physicians to perceive problems with antibiotic policies and how the policies were applied. Conclusion — The level of practitioners' awareness of their hospital's antibiotic policy and pharmacists' perception of problems with such policies need to be addressed if these policies are to make a significant contribution to improved antibiotic use in hospitals.     

The protected antimicrobial process in a University Teaching Hospital: a qualitative interview study exploring the knowledge,attitudes, and experiences of healthcare professionals

Background The protected or restricted supply of certain antimicrobials such as linezolid, caspofungin, aztreonam, in the acute hospital setting is an important element of Antimicrobial Stewardship (AMS) programmes to address the growing problem of antimicrobial resistance. This process involves submitting an application for use to be reviewed typically by a Consultant Microbiologist, Infectious Disease Consultant or Antimicrobial Pharmacist. Aim To investigate healthcare professionals’ knowledge, experiences, and attitudes towards the protected/restricted antimicrobials process in order to identify possible methods of optimisation and improvement. Method Semi-structured interviews with stakeholders involved in the protected/restricted antimicrobial prescribing, dispensing and administration process were conducted in September–October 2019 in a 350-bed voluntary, general, acute hospital in Ireland. Interviews were analysed by the Framework method and mapped to the Theoretical Domains Framework (TDF). Results Interviews were conducted with 8 Doctors, 4 Pharmacists and 3 Nurses. TDF domains identified included: ‘Knowledge’; ‘Social/professional role and identity’; ‘Social influences’; ‘Memory, attention and decision processes’; ‘Beliefs about consequences’; ‘Environmental contexts and resources’. The relationship between prescribers and the AMS Team was reported as a facilitator of the process, whereas the inconsistency of the filing and versions of forms on the wards were seen as challenges. Conclusion The results of this study have shown that the existing protected/restricted antimicrobial process is a multi-disciplinary effort with barriers that require attention in order to make future improvements. Standardization of the form across all wards, an electronic version of the form, and structured education around AMS were suggested to optimize the process.

     

Formula to help select rational antimicrobial therapy (FRAT): its application to community- and hospital-acquired urinary tract infections.

The selection of antimicrobial agents is guided by the use of formularies which often constrain prescribing options. There are several factors which influence the inclusion of specific agents. Two of the most important factors are microbial etiology of a disease and the incidence of antibiotic resistance. Various surveillance programs have highlighted the regional differences in antimicrobial susceptibility/resistance among various pathogens. This simple formula enables individual physicians, pharmacy and therapeutic committees and managed care formulary managers to harness local etiology and susceptibility information. In this paper the formula is applied to community- and hospital-acquired urinary tract infections.     

Counteracting antibiotic resistance: breaking barriers among antibacterial strategies

Introduction: To fight against antibiotic resistance, prevention-only is no longer an acceptable strategy. The old concept ‘one-infection, one-bug, one-drug’, genocentrism in antibiotic discovery, and lack of integration between different antimicrobial strategies have probably contributed to current weaknesses in confronting antibiotic resistance. Resistance should be combatted in all fronts simultaneously, in the patient (complex therapy), the group (where resistance is maintained), and the significant environment (polluted by resistance).

Areas covered: This paper is reviewing why specific ‘therapeutic’ approaches are needed in each of these fronts, using different types of ‘drugs’ directed to a variety of targets, in the goal of inhibiting antibiotic resistant bacteria. Multi-target integrated combination strategies and therapies should be more extensively evaluated, not only in the infected patient (using novel formats for clinical trials), but as associations of ‘therapeutic strategies’ in the different compartments where antibiotic resistance emerges and flows (measuring global effects in resistance).

Expert opinion: Multi-targeted therapeutic approaches require a relaxation of barriers among the various compounds, including systemic and topic antibiotics, antiseptics, biocides, anti-resistant clones vaccination, phages, decontamination products, and in general eco-evo drugs acting on factors influencing ecology and evolution of resistant bacteria. The application of methods of systems biology will facilitate such a multi-lateral attack to antibiotic resistance. Such advances should be paralleled by a simultaneous progress in regulatory sciences and close coordination among all stakeholders.     

Antimicrobial Stewardship in a Community Hospital: Attacking the More Difficult Problems

Background:

Antibiotic stewardship has been proposed as an important way to reduce or prevent antibiotic resistance. In 2001, a community hospital implemented an antimicrobial management program. It was successful in reducing antimicrobial utilization and expenditure. In 2011, with the implementation of a data-mining tool, the program was expanded and its focus transitioned from control of antimicrobial use to guiding judicious antimicrobial prescribing.

Objective:

To test the hypothesis that adding a data-mining tool to an existing antimicrobial stewardship program will further increase appropriate use of antimicrobials.

Design:

Interventional study with historical comparison.

Methods:

Rules and alerts were built into the data-mining tool to aid in identifying inappropriate antibiotic utilization. Decentralized pharmacists acted on alerts for intravenous (IV) to oral conversion, perioperative antibiotic duration, and restricted antimicrobials. An Infectious Diseases (ID) Pharmacist and ID Physician/Hospital Epidemiologist focused on all other identified alert types such as antibiotic de-escalation, bug-drug mismatch, and double coverage. Electronic chart notes and phone calls to physicians were utilized to make recommendations.

Results:

During 2012, 2,003 antimicrobial interventions were made with a 90% acceptance rate. Targeted broad-spectrum antimicrobial use decreased by 15% in 2012 compared to 2010, which represented cost savings of $1,621,730. There were no statistically significant changes in antimicrobial resistance, and no adverse patient outcomes were noted.

Conclusions:

The addition of a data-mining tool to an antimicrobial stewardship program can further decrease inappropriate use of antimicrobials, provide a greater reduction in overall antimicrobial use, and provide increased cost savings without negatively affecting patient outcomes.Key Words: antimicrobial stewardship, data-mining tool, patient outcome metrics, process metrics, recommendationsAntibiotic stewardship has been proposed as an important way to reduce antibiotic resistance and preserve the limited armamentarium of antibiotics. In many hospitals, antibiotic stewardship programs were implemented in response to an outbreak caused by multidrug-resistant (MDR) organisms. In 2001, Texas Health Presbyterian Hospital of Dallas implemented a Comprehensive Antimicrobial Management Program (CAMP) in the absence of an outbreak of MDR infections. It was conceived as a quality improvement project to address the growing concerns of antibiotic misuse.¹ Inappropriate antibiotic prescribing is a major concern as rates of health care-associated infections and antimicrobial resistance continue to rise. It has been estimated that up to 50% of antimicrobial use is inappropriate.² Prior to September 2011, interventions by CAMP were limited to conversion from intravenous (IV) to oral administration for highly bioavailable antimicrobials; discontinuation of perioperative antimicrobial prophylaxis at 24 hours for clean and clean-contaminated surgical procedures; and restriction of use of antibiotics that have a high risk for adverse events, have a high potential to promote resistance, or are expensive. Inappropriate utilization was not analyzed due to limited resources.This program was successful in reducing antibiotic expenditures and was associated with modest improvements in antibiotic susceptibility.¹ However, it was largely noninterventional for monitoring antibiotic choice; it relied on physicians to voluntarily comply with policies on “restricted antibiotics.” After publication of the 2007 Infectious Disease Society of America (IDSA) practice guideline on antibiotic stewardship, it became clear that a more interventional program with rapid feedback was needed to ensure optimal use of antibiotics.³ With the advent of data-mining programs (eg, Sentri7, TheraDoc, SafetySurveillor) that interface with electronic health records (EHRs), it became possible to survey, in real-time, multiple different antibiotics, culture results, and clinical diagnoses. In Sentri7, the Infectious Disease (ID) Pharmacist has the administrative capability to create rules without the need for external or hospital information technology (IT) support. Currently, our EHR cannot data mine clinical microbiology information, and any additional rule build would require IT programming. Kullar and colleagues describe several other limitations with their EHR (EPIC).⁴     

A Qualitative Analysis of Implementation of Antimicrobial Stewardship at 3 Academic Hospitals: Understanding the Key Influences on Success

Background:

Inappropriate use of antimicrobials is linked to the development and spread of drug-resistant pathogens and is associated with increased morbidity, mortality, lengths of hospital stay, and health care costs. “Antimicrobial stewardship” is the umbrella term for an evidence-based knowledge translation strategy involving comprehensive quality improvement activities to optimize the use of antimicrobials, improve patient outcomes, reduce the development of antimicrobial resistance and hospital-acquired infections such as Clostridium difficile, and decrease health care costs.

Objective:

To assess the perceptions and experiences of antimicrobial stewardship program leaders in terms of clinicians’ attitudes toward and behaviours related to antimicrobial prescribing.

Methods:

In this qualitative study, semistructured interviews were conducted with 6 antimicrobial stewards (2 physicians and 4 pharmacists) at 3 academic hospitals between June and August 2013.

Results:

The following 3 key themes emerged from the interviews: getting the right people on board, building collegial relationships, and rapidly establishing a track record. The study results elucidated the role and mechanisms that the program leader and other antimicrobial stewards used to influence other clinicians to engage in effective utilization of antimicrobials. The results also highlighted the methods employed by members of the antimicrobial stewardship team to tailor their strategies to the local context and to stakeholders of participating units; to gain credibility by demonstrating the impact of the antimicrobial stewardship program on clinical outcomes and cost; and to engage senior leaders to endorse and invest in the antimicrobial stewardship program, thereby adding to the antimicrobial stewards’ credibility and their ability to influence the uptake of effective antimicrobial use.

Conclusions:

Collectively, these results offer insight into processes and mechanisms of influence employed by antimicrobial stewards to enhance antimicrobial use among clinicians, which can in turn inform future implementation of antimicrobial stewardship and strategies for organizational change in hospitals.     

Optimising antibiotic prescribing in primary care.

Prudent antimicrobial prescribing in the community may help to prevent the relentless increase in resistance, highlighted worldwide by numerous parliamentary documents. Antibiotic guidance, developed by primary care professionals and disseminated locally with outreach workshops, helps to reduce the use of broad-spectrum antimicrobials. Computerised guidance, audit of antibiotic use and restricted laboratory sensitivity reporting moves the prescriber towards the selection of recommended drugs. Educational campaigns and patient leaflets given at the consultation help to modify patients' expectations. Primary care physicians need to consider how much pharmaceutical representatives and free samples influence their prescribing. This multi-faceted approach needs to be backed up with a research programme developing the evidence base for management guidance of antimicrobial use in primary care.     

Impact of an antimicrobial stewardship programme on patient safety in Singapore General Hospital

Whilst studies have shown that antimicrobial stewardship programmes (ASPs) can effectively reduce antibiotic utilisation, cost of care and even antimicrobial resistance rates, ASPs should avoid the perception that the goal is primarily to reduce antibiotic purchases and costs, instead of focusing on improving the quality of care. In addition, to address the concern of primary physicians who deemed that ASPs' choices of antibiotics were often inadequate, the impact of ASPs on patient safety should be monitored and evaluated. The aim of this study was to analyse the impact of ASP interventions on patient safety in Singapore General Hospital (SGH), a 1559-bed, large, acute, tertiary-care hospital in Singapore. A retrospective database review of data on ASP interventions issued between October 2008 and September 2010 was performed. The database maintained by the ASP team detailed patients' demographic data as well as outcomes of issued interventions. The ASP recommended 1256 interventions in a total of 1249 admissions in six departments. Shorter average length of stay (mean ± standard deviation 19.4 ± 19.9 days vs. 24.2 ± 24.2 days) was observed among patients of physicians who accepted ASP suggestions compared with patients of physicians who rejected ASP interventions (P<0.01). ASP interventions did not alter all-cause mortality (P=0.191). In addition, the number of infection-related re-admissions (P<0.001) and the 14-day re-infection rate (P=0.009) were higher among patients whose physicians rejected ASP interventions. In conclusion, interventions recommended by the ASP in SGH were safe and were associated with a reduction in the duration of hospital stay, 14-day re-infection rate and infection-related re-admissions.