Antimicrobial Stewardship Interventions: Narrative Review

Antibiotic Use ◽

Narrative Review ◽

Health Concern

Antimicrobial resistance is a serious health concern with significant economic and clinical sequelae. Antimicrobial stewardship programs are increasingly being promoted and mandated in order to rationalize and reduce the use of antimicrobials in healthcare institutions and as a result decrease antimicrobial resistance. Several interventions could be used to improve antibiotic use that includes broad, pharmacy driven and infection and syndrome specific interventions. Each hospital should prioritize interventions based on its needs as well as based on the availability of resources and content expertise.

Knowledge, Attitudes and Practices of Veterinarians Towards Antimicrobial Resistance and Stewardship in Nigeria

Antibiotics ◽

10.3390/antibiotics9080453 ◽

2020 ◽

Vol 9 (8) ◽

pp. 453

Author(s):

Usman O. Adekanye ◽

Abel B. Ekiri ◽

Erika Galipó ◽

Abubakar Bala Muhammad ◽

Ana Mateus ◽

...

Keyword(s):

Online Survey ◽

Action Plan ◽

Prophylactic Antibiotic ◽

Antibiotic Use ◽

Health Concern ◽

Attitudes And Practices ◽

Laboratory Services ◽

Knowledge Attitudes And Practices

Antimicrobial resistance (AMR) is a global health concern and the inappropriate use of antibiotics in animals and humans is considered a contributing factor. A cross-sectional survey to assess the knowledge, attitudes and practices of veterinarians regarding AMR and antimicrobial stewardship was conducted in Nigeria. A total of 241 respondents completed an online survey. Only 21% of respondents correctly defined the term antimicrobial stewardship and 59.8% were unaware of the guidelines provided by the Nigeria AMR National Action Plan. Over half (51%) of the respondents indicated that prophylactic antibiotic use was appropriate when farm biosecurity was poor. Only 20% of the respondents conducted antimicrobial susceptibility testing (AST) frequently, and the unavailability of veterinary laboratory services (82%) and the owner’s inability to pay (72%) were reported as key barriers to conducting AST. The study findings suggest strategies focusing on the following areas may be useful in improving appropriate antibiotic use and antimicrobial stewardship among veterinarians in Nigeria: increased awareness of responsible antimicrobial use among practicing and newly graduated veterinarians, increased dissemination of regularly updated antibiotic use guidelines, increased understanding of the role of good biosecurity and vaccination practices in disease prevention, and increased provision of laboratory services and AST at affordable costs.

Assessing Knowledge and Perception Regarding Antimicrobial Stewardship and Antimicrobial Resistance in University Students of Pakistan: Findings and Implications

Antibiotics ◽

10.3390/antibiotics10070866 ◽

2021 ◽

Vol 10 (7) ◽

pp. 866

Author(s):

Iltaf Hussain ◽

Nisa Yousaf ◽

Sana Haider ◽

Pervisha Jalil ◽

Muhammad Usman Saleem ◽

...

Keyword(s):

University Students ◽

Antibiotic Use ◽

Cross Sectional Study ◽

Dosing Regimen ◽

Student Knowledge ◽

Chi Square ◽

Cross Sectional ◽

Self Administered Questionnaire

The irrational use of antimicrobials has enormously contributed to antimicrobial resistance (AMR) globally and especially in the developing world. To assess the knowledge and perception regarding AMR and antimicrobial stewardship (AMS), a descriptive cross-sectional study was carried out in university students enrolled in pharmacy, veterinary, and biology programs by using an online self-administered questionnaire. The Chi-square and Fisher exact tests (where applicable) were performed to assess the association of the demographics with the students’ knowledge and perception regarding AMR and AMS. A total of 496 students completed the questionnaire, among which, 85.7% of the participants were familiar with the term AMR and 79.4% of the participants correctly identified a poorly designed dosing regimen as a contributing factor towards AMR. The majority of participants (57.9%) were familiar with the term AMS and 86.5% were aware of the aim of AMS. The participants showed good knowledge regarding AMR and AMS, but to further improve student knowledge and perception of AMS and AMR, it is suggested that dedicated modules on antibiotic use and AMS should be incorporated into the curricula of these undergraduate and postgraduate programs.

Unsafe “crossover-use” of chloramphenicol in Uganda: importance of a One Health approach in antimicrobial resistance policy and regulatory action

The Journal of Antibiotics ◽

10.1038/s41429-021-00416-3 ◽

2021 ◽

Author(s):

Kayley D. McCubbin ◽

John W. Ramatowski ◽

Esther Buregyeya ◽

Eleanor Hutchinson ◽

Harparkash Kaur ◽

...

Keyword(s):

Focus Group ◽

Low Income ◽

One Health ◽

Antibiotic Use ◽

Regulatory Action ◽

Health Concern ◽

Drug Shop ◽

Human Consumption ◽

Human Use

AbstractSince the introduction of antibiotics into mainstream health care, resistance to these drugs has become a widespread issue that continues to increase worldwide. Policy decisions to mitigate the development of antimicrobial resistance are hampered by the current lack of surveillance data on antibiotic product availability and use in low-income countries. This study collected data on the antibiotics stocked in human (42) and veterinary (21) drug shops in five sub-counties in Luwero district of Uganda. Focus group discussions with drug shop vendors were also employed to explore antibiotic use practices in the community. Focus group participants reported that farmers used human-intended antibiotics for their livestock, and community members obtain animal-intended antibiotics for their own personal human use. Specifically, chloramphenicol products licensed for human use were being administered to Ugandan poultry. Human consumption of chloramphenicol residues through local animal products represents a serious public health concern. By limiting the health sector scope of antimicrobial resistance research to either human or animal antibiotic use, results can falsely inform policy and intervention strategies. Therefore, a One Health approach is required to understand the wider impact of community antibiotic use and improve overall effectiveness of intervention policy and regulatory action.

Where to from here? Identifying and prioritising future directions for addressing drug-resistant infection in Australia

Antimicrobial Resistance and Infection Control ◽

10.1186/s13756-021-00953-4 ◽

2021 ◽

Vol 10 (1) ◽

Author(s):

Gregory Merlo ◽

Minyon Avent ◽

Trent Yarwood ◽

Bonnie Smith ◽

Mieke van Driel ◽

...

Keyword(s):

Infection Prevention ◽

Implementation Strategies ◽

Antibiotic Use ◽

Future Directions ◽

World Cafe ◽

Resistant Infection ◽

Using Data ◽

Patient Stories

Abstract Background The Australian National Antimicrobial Resistance Strategy calls for a collaborative effort to change practices that have contributed to the development of drug-resistance and for implementation of new initiatives to reduce antibiotic use. Methods A facilitated workshop was undertaken at the 2019 National Australian Antimicrobial Resistance Forum to explore the complexity of antimicrobial stewardship (AMS) implementation in Australia and prioritise future action. Participants engaged in rotating rounds of discussion using a world café format addressing six topics relating to AMS implementation. Once all tables had discussed all themes the discussion concluded and notes were summarised. The documents were independently openly coded by two researchers to identify elements relating to the implementation of antimicrobial stewardship. Results There were 39 participants in the facilitated discussions, including pharmacists, infectious disease physicians, infection prevention nurses, and others. Participants discussed strategies they had found successful, including having a regular presence in clinical areas, adapting messaging and implementation strategies for different disciplines, maintaining positivity, and being patient-focused. Many of the recommendations for the next step involved being patient focussed and outcomesdriven. This involves linking data to practice, using patient stories, using data to celebrate wins and creating incentives. Discussion Recommendations from the workshop should be included in priority setting for the implementation of AMS initiatives across Australia.

Antimicrobial stewardship in rural and remote primary health care: a narrative review

Antimicrobial Resistance and Infection Control ◽

10.1186/s13756-021-00964-1 ◽

2021 ◽

Vol 10 (1) ◽

Author(s):

Jun Wern Yau ◽

Sze Mun Thor ◽

Danny Tsai ◽

Tobias Speare ◽

Chris Rissel

Keyword(s):

Health Care ◽

Primary Health Care ◽

Inappropriate Prescribing ◽

Narrative Review ◽

Rural And Remote ◽

Antimicrobial Prescribing ◽

Primary Health ◽

Resistance Rates

Abstract Background Antimicrobial 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. Methods The 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. Results Fifty-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. Conclusions Inappropriate 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.

Antimicrobial Stewardship in the Emergency Department

Journal of Pharmacy Practice ◽

10.1177/0897190015585762 ◽

2016 ◽

Vol 29 (6) ◽

pp. 556-563 ◽

Cited By ~ 21

Author(s):

Bryan M. Bishop

Keyword(s):

Emergency Department ◽

Health Concern ◽

Antimicrobial Use ◽

Upper Respiratory Infection ◽

Diagnostic Uncertainty ◽

National Public Health ◽

Inpatient Settings ◽

Tract Infections

Antimicrobial resistance is a national public health concern. Misuse of antimicrobials for conditions such as upper respiratory infection, urinary tract infections, and cellulitis has led to increased resistance to antimicrobials commonly utilized to treat those infections, such as sulfamethoxazole/trimethoprim and flouroquinolones. The emergency department (ED) is a site where these infections are commonly encountered both in ambulatory patients and in patients requiring admission to a hospital. The ED is uniquely positioned to affect the antimicrobial use and resistance patterns in both ambulatory settings and inpatient settings. However, implementing antimicrobial stewardship programs in the ED is fraught with challenges including diagnostic uncertainty, distractions secondary to patient or clinician turnover, and concerns with patient satisfaction to name just a few. However, this review article highlights successful interventions that have stemmed inappropriate antimicrobial use in the ED setting and warrant further study. This article also proposes other, yet to be validated proposals. Finally, this article serves as a call to action for pharmacists working in antimicrobial stewardship programs and in emergency medicine settings. There needs to be further research on the implementation of these and other interventions to reduce inappropriate antimicrobial use to prevent patient harm and curb the development of antimicrobial resistance.

Impact of a mobile decision support tool on antimicrobial stewardship indicators in St. John’s, Canada

PLoS ONE ◽

10.1371/journal.pone.0252407 ◽

2021 ◽

Vol 16 (6) ◽

pp. e0252407

Author(s):

Daniel Doyle ◽

Gerald McDonald ◽

Claire Pratt ◽

Zahra Rehan ◽

Tammy Benteau ◽

...

Keyword(s):

Decision Support ◽

Cost Savings ◽

Antibiotic Use ◽

Defined Daily Dose ◽

Support Tool ◽

Survey Tool ◽

Before And After ◽

The Impact

Objectives Inappropriate antibiotic use contributes to antimicrobial resistance. The SpectrumTM app provides antibiotic decision support, based on local antimicrobial resistance rates. We determined the impact of regional implementation of the app on inpatient antimicrobial appropriateness, inpatient antimicrobial usage (AMU), population-based Clostridioides difficile infection (CDI) rates and cost, using a retrospective, before and after quasi-experimental design, including a one-year study period. Methods The SpectrumTM app was released to prescribers in February, 2019. We performed two one-day inpatient point prevalence surveys using the National Antimicrobial Prescribing Survey tool, six months before (June 25, 2018) and six months after (June 25, 2019) app dissemination. Inpatient AMU in Defined Daily Dose/1000 patient days and CDI incidence were compared, before and after app dissemination. Results The pre-survey included 184 prescriptions, and the post-survey included 197 prescriptions. Appropriateness was 97/176 (55.1%) pre, and 126/192 (65.6%) post (+10.5%, p = 0.051). Inpatient AMU declined by 6.6 DDD/1000 patient days per month, and CDI declined by 0.3 cases per month. Cost savings associated with reduced AMU were $403.98/bed/year and associated with reduced CDI were $82,078/year. Conclusion We observed improvement in antimicrobial stewardship indicators following SpectrumTM implementation. We cannot determine the cause of these improvements.

Perceptions, Current Practices and Interventions of Community Pharmacists Regarding Antimicrobial Stewardship: A Qualitative Study in France

10.21203/rs.3.rs-1033731/v1 ◽

2021 ◽

Author(s):

Claire Durand ◽

Aude Chappuis ◽

Eric Douriez ◽

Frédérique Poulain ◽

Raheelah Ahmad ◽

...

Keyword(s):

Primary Care ◽

Health Care ◽

Community Health ◽

Thematic Analysis ◽

Community Pharmacists ◽

Antibiotic Use ◽

Antibiotic Prescribing ◽

Community Health Care

Abstract Background: Community 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. This study aimed to explore the perceptions, currents practices and interventions of community pharmacists regarding antimicrobial stewardship.Methods: Semi-structured 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.Results: Sixteen community pharmacists participated. All the respondents had good awareness about antimicrobial resistance and believed 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 as well as financial incentives. Conclusions: This 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.

Evaluating and prioritizing antimicrobial stewardship programs for nursing homes: A modified Delphi panel

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.214 ◽

2020 ◽

Vol 41 (9) ◽

pp. 1028-1034

Author(s):

Shaul Z. Kruger ◽

Susan E. Bronskill ◽

Lianne Jeffs ◽

Marilyn Steinberg ◽

Andrew M. Morris ◽

...

Keyword(s):

Nursing Home ◽

Nursing Homes ◽

Antibiotic Use ◽

Educational Interventions ◽

Audit And Feedback ◽

Delphi Panel ◽

Scientific Merit ◽

Modified Delphi

AbstractBackground:Antibiotic use in nursing homes is often inappropriate, in terms of overuse and misuse, and it can be linked to adverse events and antimicrobial resistance. Antimicrobial stewardship programs (ASPs) can optimize antibiotic use by minimizing unnecessary prescriptions, treatment cost, and the overall spread of antimicrobial resistance. Nursing home providers and residents are candidates for ASP implementation, yet guidelines for implementation are limited.Objective:To support nursing home providers with the selection and adoption of ASP interventions.Design and Setting:A multiphase modified Delphi method to assess 15 ASP interventions across criteria addressing scientific merit, feasibility, impact, accountability, and importance. This study included surveys supplemented with a 1-day consensus meeting.Participants:A 16-member multidisciplinary panel of experts and resident representatives.Results:From highest to lowest, 6 interventions were prioritized by the panel: (1) guidelines for empiric prescribing, (2) audit and feedback, (3) communication tools, (4) short-course antibiotic therapy, (5) scheduled antibiotic reassessment, and (6) clinical decision support systems. Several interventions were not endorsed: antibiograms, educational interventions, formulary review, and automatic substitution. A lack of nursing home resources was noted, which could impede multifaceted interventions.Conclusions:Nursing home providers should consider 6 key interventions for ASPs. Such interventions may be feasible for nursing home settings and impactful for improving antibiotic use; however, scientific merit supporting each is variable. A multifaceted approach may be necessary for long-term improvement but difficult to implement.

Antimicrobial Stewardship

Tutorial Topics in Infection for the Combined Infection Training Programme ◽

10.1093/oso/9780198801740.003.0028 ◽

2019 ◽

Author(s):

Sarfaraz Ameen ◽

Caoimhe NicFhogartaigh

Keyword(s):

Clinical Outcomes ◽

Length Of Hospital Stay ◽

Health Concern ◽

Resistant Bacteria ◽

Global Public Health ◽

National Guidelines ◽

Minor Operations ◽

The Right

Antimicrobial stewardship (AMS) is a healthcare- system- wide approach to promoting and monitoring the judicious use of antimicrobials (including antibiotics) to preserve their future effectiveness and optimize outcomes for patients. Put simply, it is using the right antibiotic, at the right dose, via the right route, at the right time, for the right duration (Centres for Disease Control, 2010). Antimicrobial resistance (AMR) is a serious and growing global public health concern. Antibiotics are a unique class of drug as their use in individual patients may have an impact on others through the spread of resistant organisms. Antibiotics are essential for saving lives in conditions such as sepsis, and without effective antibiotics even minor operations could be life-threatening due to the risk of resistant infections. Across Europe approximately 25,000 people die each year as a result of hospital infections caused by resistant bacteria, and others have more prolonged and complicated illness. By 2050, AMR is predicted to be one of the major causes of death worldwide. Protecting the use of currently available antibiotics is crucial as discovery of new antimicrobials has stalled. Studies consistently demonstrate that 30–50% of antimicrobial prescriptions are unnecessary or inappropriate. Figure 18.1 shows some of the reasons behind this. As well as driving increasing resistance, unnecessary prescribing leads to unwanted adverse effects, including avoidable drug reactions and interactions, Clostridium difficile-associated diarrhoea, and healthcare-associated infections with resistant micro-organisms, all of which are associated with adverse clinical outcomes, including increased length of hospital stay and mortality, with increased cost to healthcare systems. Prudent use of antibiotics improves patient care and clinical outcomes, reduces the spread of antimicrobial resistance, and saves money. There are a number of global and national guidelines outlining what a robust AMS programme should consist of (see Further reading and useful resources), including: ● Infectious Diseases Society of America (IDSA): Guidelines for Developing an Institutional Programme to Enhance Antimicrobial Stewardship. ● National Institute for Health and Care Excellence (NICE): Antimicrobial Stewardship: Systems and Processes for Effective Antimicrobial Medicine Use [NG15]. ● Department of Health (DoH): Start Smart Then Focus, updated 2015. ● DoH: UK 5- Year Antimicrobial Resistance Strategy 2013 to 2018.