Antimicrobial Stewardship Activities Research Articles

Knowledge, awareness and practices of healthcare workers regarding antimicrobial use, resistance and stewardship in Zambia: a multi-facility cross-sectional study.

Antimicrobial resistance (AMR) poses a threat to public health globally. Despite its consequences, there is little information about the knowledge, awareness, and practices towards AMR among healthcare workers (HCWs). Therefore, this study assessed the knowledge, awareness and practices regarding antimicrobial use (AMU), AMR and antimicrobial stewardship (AMS) among HCWs who are involved in the implementation of AMS activities across eight hospitals in Zambia. A cross-sectional study was conducted among 64 HCWs from October to December 2023 using a semi-structured questionnaire. Data were analysed using IBM SPSS version 25.0. Of the 64 HCWs, 59.4% were females, 60.9% were aged between 25 and 34 years, 37.5% were nurses, 18.7% were pharmacists, 17.2% were medical doctors and only one was a microbiologist. Overall, 75% of the HCWs had good knowledge, 84% were highly aware and 84% had good practices regarding AMU, AMR and AMS. Most of the HCWs (90.6%) responded that they had a multidisciplinary AMS team at their hospitals and were implementing the use of the WHO AWaRe classification of antibiotics. This study found good knowledge levels, high awareness and good practices regarding AMU, AMR and AMS among HCWs who were involved in the implementation of AMS activities in hospitals in Zambia. Additionally, most hospitals have been conducting AMS training and implementing the use of the WHO AWaRe classification of antibiotics. However, there is still a need to address some identified gaps in AMU and AMR through the strengthening of AMS activities in hospitals.

Pharmacist-Led Antimicrobial Stewardship Programme in Two Tertiary Hospitals in Malawi

The ultimate goal of antimicrobial stewardship (AMS) programmes is to decrease the occurrence and spread of antimicrobial resistance (AMR). In response to this, a pharmacist partnership was established between Malawi and Wales (UK) with the aim of strengthening antimicrobial stewardship (AMS) activities in Malawi, with the initial project focusing on two tertiary referral hospitals. The Global Point Prevalence Survey (GPPS) was undertaken for the first time in Malawi at these sites and demonstrated a prescribing rate slightly lower than the African average, with ceftriaxone indicated for almost every bacterial infection. An educational intervention was also delivered, with a train-the-trainer approach upskilling pharmacists at the two sites, who then cascaded co-produced training sessions to an additional 120 multidisciplinary health professionals. A toolkit to support AMS at an individual patient level was also developed and disseminated to provide an ongoing reference to refer to. Both the trainings and toolkit were well received. Over the course of this project, significant progress has been made with the AMS programmes at the two sites, with local staff empowered to implement AMS activities. These interventions could be easily replicated and scaled and support the delivery of some of the AMS elements of the Malawi Ministry of Health National Action Plan for Antimicrobial Resistance.

Pharmacovigilance Strategies to Address Resistance to Antibiotics and Inappropriate Use-A Narrative Review.

The spread of antimicrobial resistance (AMR) is a global challenge. Close and continuous surveillance for quick detection of AMR can be difficult, especially in remote places. This narrative review focuses on the contributions of pharmacovigilance (PV) as an auxiliary tool for identifying and monitoring the ineffectiveness, resistance, and inappropriate use of antibiotics (ABs). The terms "drug ineffective", "therapeutic failure", "drug resistance", "pathogen resistance", and "multidrug resistance" were found in PV databases and dictionaries, denoting ineffectiveness. These terms cover a range of problems that should be better investigated because they are useful in warning about possible causes of AMR. "Medication errors", especially those related to dose and indication, and "Off-label use" are highlighted in the literature, suggesting inappropriate use of ABs. Hence, the included studies show that the terms of interest related to AMR and use are not only present but frequent in PV surveillance programs. This review illustrates the feasibility of using PV as a complementary tool for antimicrobial stewardship activities, especially in scenarios where other resources are scarce.

Impact of COVID-19 on antimicrobial stewardship activities in Italy: a region-wide assessment

BackgroundIn the region of Piedmont, in Northern Italy, formal monitoring of antimicrobial stewardship (AMS) programs has been in place since 2012. The objective of our study was to provide an updated assessment of AMS programs operating in our region, and to assess the impact of the COVID-19 pandemic on stewardship activities.MethodsA retrospective observational study was conducted to investigate AMS programs implemented in acute-care trusts participating in a broader healthcare-associated infections and antimicrobial resistance (AMR) prevention and control program, promoted by the regional health department. Within this program, structure, process, and outcome indicators of AMS programs were investigated, using a previously developed scoring system. Differences between scores prior to (2019) and during the pandemic (2021) were assessed. Linear regression was used to assess whether the 5-year trends (2017–2021) in outcome measures in relation to structure and process scores were statistically significant. Compound annual growth rates (CAGR) for each outcome were calculated to illustrate changes in outcome rates over time.ResultsAll public trusts in the Region (20) and a small number of private institutions (3) provided data for this study. A modest, non-significant improvement was found for 2021 structure, process, and total scores compared to respective 2019 scores. A significant improvement was found concerning the definition of a formal mission statement, whereas significantly less trusts included monitoring adherence to antimicrobial policy or treatment guidelines in their programs. Overall consumption of antibiotics for systemic use saw an increase in 2021, with 2021 recording the highest median overall consumption compared to all previous years considered in this study. Methicillin-resistant Staphylococcus aureus (MRSA) and carbapenem-resistant enterobacteria (CRE) rates decreased over the 5-year period. Significant downwards trends in MRSA rates were identified for high-outlier structure and process groups.ConclusionsResults of this study suggest AMS programs in Piedmont were not set back following the pandemic. This outcome was possible thanks to well-established programs, coordinated within a regional framework. Continued efforts should be dedicated to supporting AMS programs and contrasting AMR, even when the focus is shifted towards other public health emergencies.

Oral antibacterial drug prescribing in primary care out-of-hours services in Wales: a secondary analysis study

Abstract Introduction Antibacterial drug consumption is posing significant threats and contributing to antimicrobial resistance.[1] Individuals are frequently exposed to antibacterials, either with intentional use or unintentionally through environmental contamination, such as when drug residues are excreted into water resources.[2] To address these concerns and promote sustainability in human health and the environment, adopting rational prescribing practices is essential, especially in primary care (PC) settings where antibacterial prescribing is high. Healthcare practitioners often face various challenges when prescribing these drugs. The challenges are more pronounced in out-of-hours (OOH) encounters, where additional factors, including managing unfamiliar patients and limited safety netting, further complicate their prescribing decisions. Limited research has been conducted in these settings until recently, and the evidence in Wales is lacking. Aim Investigate oral antibacterial drug prescribing volume over time in PC, focusing on OOH services. Methods Retrospective descriptive analyses on All-Wales antibacterial prescriptions were carried out using longitudinal secondary data that were readily available when data was accessed, i.e., between the financial years 2015-16 and 2021-22. National Health Service financial years cover the period from April to March. These routinely collected data, which are not publicly available, were requested from All-Wales Therapeutics and Toxicology Centre and extracted from the Comparative Analysis System for Prescribing Audit (CASPA), an electronic-based system used by Wales Shared Services Partnership to maintain records of PC prescriptions dispensed in the community. Number of items prescribed during daytime and OOH services was obtained for all antibacterials and the 4Cs associated with Clostridioides difficile infections (co-amoxiclav, clindamycin, cephalosporins, quinolones). Data were processed and adjusted per 100,000 population using mid-year estimates, and the overall percentage changes in volumes were calculated. Results The total number of items prescribed in PC was 14,997,291, of which 1,265,499 (8.44%) were 4Cs. For OOH services, the total number of items was 445,339 (3% of PC); 4Cs accounted for 50,527 (11.35% of OOH, 4% of PC 4Cs). OOH antibacterial and 4Cs prescribing represented relatively small proportions over the 7-year period in relation to PC, ranging between 2.7%-3.2% and 3.6%-4.2%, respectively. Data revealed a decline in prescribing in PC as a whole and OOH services, reaching its lowest in 2020-21 when COVID-19 hit. Throughout the study, prescribing volume per 100,000 population decreased by 20.7% in PC and 31.2% in OOH services when examining all oral antibacterials, and by 40.9% and 38.5%, respectively, when examining 4Cs. Data from 2021-22 indicated a rise (14% in PC; 19% in OOH) in total antibacterial prescriptions from the previous year. Conclusion To our knowledge, this study is the first to examine oral antibacterial prescribing volume in Wales OOH services, revealing downward trends of prescribing in PC generally and OOH services. The reduction in PC was primarily driven by daytime prescribing, where most consultations usually take place. Various factors may contribute to this reduction, warranting further exploration of antimicrobial stewardship activities. Additionally, investigating COVID-19 potential impact on prescribing and its sustainability is crucial. Qualitative interviews are ongoing with lead antimicrobial pharmacists in Wales, to understand the observed trends and uncover their underlying driving causes.

The application of antimicrobial stewardship knowledge to nursing practice: A national survey of United Kingdom pre-registration nursing students.

To assess student nurses understanding and skills in the application of antimicrobial stewardship knowledge to practice. Quantitative. Cross-sectional survey. Five hundred and twenty three student nurses responded across 23 UK universities. Although students felt prepared in competencies in infection prevention and control, patient-centred care and interprofessional collaborative practice, they felt less prepared in competencies in which microbiological knowledge, prescribing and its effect on antimicrobial stewardship is required. Problem-based learning, activities in the clinical setting and face-to-face teaching were identified as the preferred modes of education delivery. Those who had shared antimicrobial stewardship teaching with students from other professions reported the benefits to include a broader understanding of antimicrobial stewardship, an understanding of the roles of others in antimicrobial stewardship and improved interprofessional working. There are gaps in student nurses' knowledge of the basic sciences associated with the antimicrobial stewardship activities in which nurses are involved, and a need to strengthen knowledge in pre-registration nurse education programmes pertaining to antimicrobial management, specifically microbiology and antimicrobial regimes and effects on antimicrobial stewardship. Infection prevention and control, patient-centred care and interprofessional collaborative practice are areas of antimicrobial stewardship in which student nurses feel prepared. Interprofessional education would help nurses and other members of the antimicrobial stewardship team clarify the role nurses can play in antimicrobial stewardship and therefore maximize their contribution to antimicrobial stewardship and antimicrobial management. There is a need to strengthen knowledge from the basic sciences, specifically pertaining to antimicrobial management, in pre-registration nurse education programmes. No patient or public contribution. What Problem Did the Study Address? Nurses must protect health through understanding and applying antimicrobial stewardship knowledge and skills (Nursing and Midwifery Council 2018); however, there is no research available that has investigated nurses understanding and skills of the basic sciences associated with the antimicrobial stewardship activities in which they are involved. What Were the Main Findings? There are gaps in student nurses' knowledge of the basic sciences (specifically microbiology and prescribing) associated with the antimicrobial stewardship activities in which nurses are involved. Problem-based learning, and activities in the clinical setting, were reported as useful teaching methods, whereas online learning, was seen as less useful. Where and on Whom Will the Research Have an Impact? Pre-registration nurse education programmes. The relevant reporting method has been adhered to, that is, STROBE.

Introduction of antimicrobial resistance education in pharmacy curricula in India: Lessons learned and future direction

IntroductionInsufficient training in antimicrobial resistance (AMR) and antimicrobial stewardship (AMS) in the pharmacy curricula limits pharmacists’ participation in AMS activities in India. We explored the potential impact of an AMR curriculum implemented as part of a research project in one of the pharmacy colleges in Kerala, India. MethodsData were collected using documentary analysis (minutes of meetings and the AMR curriculum developed) and semi-structured qualitative interviews with key informants face-to-face or via the Zoom platform at the participant's convenience. Anonymized interview transcripts were thematically analyzed aided by NVivo 12 software. ResultsWe interviewed faculty (n = 4), clinical pharmacists (n = 3), and students (n = 6) involved in the design, implementation, and use of the new curriculum. The development and implementation of the new curriculum was conducted through strategically planned and established methodology with equal involvement from the pharmacy college and the research project team. Challenges in this process included a lack of human resources to take classes, time, limited interactions, and motivation of students during the online classes. Despite this, students who attended the classes agreed that the curriculum introduced them to AMS and AMR concepts which helped them during their clinical postings. They agreed that it would be beneficial if a similar curriculum was implemented in other pharmacy colleges. ConclusionLearnings from this study would be beneficial for other pharmacy colleges to implement a similar AMR curriculum for training pharmacy students to take key roles in AMS, especially in countries like India where postgraduate training for pharmacists remains limited.

Antimicrobial resistance and stewardship: What do pharmacists know and practice in a major Nigerian tertiary health facility: A cross-sectional study

Background: Multidrug-resistant bacterial infections are still a global challenge and successful antimicrobial stewardship (AMS) requires multidisciplinary collaborative partnership. Studies have highlighted the knowledge and perceptions of pharmacists, but there is a paucity of data about practices of pharmacists in teaching hospitals in Nigeria. We set out to determine the knowledge and practices of pharmacists in a major tertiary health facility (THF) in Lagos, Nigeria, before starting an AMS intervention program. Methods: This cross-sectional survey used electronic forms to find out the knowledge and practices of pharmacists employed in a large tertiary health facility. Data were collected during a Commonwealth Partnerships for AMS program to support low- and middle-income countries to produce antimicrobial consumption surveillance data, quality improvement initiatives, and infection prevention and control (IPC) processes. Results: Two-thirds of respondents knew that antibiotics were effective against bacteria, and 48.6% knew the causes of antimicrobial resistance. Almost all (97.1%) agreed that AMS must be done, IPC is important, and they were confident to point out inappropriate prescribing. Three-quarters had advised colleagues or been involved in AMS activities; however, 62.9% had fully or mostly changed their practices based on information received, and 26.5% had participated in World Antibiotic Awareness Week. Conclusion: There are still gaps in knowledge and practices, which underscore the need to entrench regular training on the job. However, there is overall awareness of AMS and a desire for it to be carried out at all levels. Pharmacists are useful for choosing appropriate antibiotics and can play a vital role in AMS.

Antibiotic consumption in French nursing homes between 2018 and 2022: A multicenter survey.

Monitoring antibiotic consumption is a key component to steer antimicrobial stewardship programs, including in nursing homes. We analyzed changes in antibiotic consumption in French nursing homes during 5 years, including the COVID-19 pandemic, to identify potential priorities for improvement. A multicenter survey was conducted between 2018 and 2022. The study was conducted across 220 French nursing homes with on-site pharmacies. Antibiotic consumption data were collected from pharmacy records and are expressed as defined daily doses per 1,000 resident days. Antibiotic indicators promoted by health authorities were calculated from quantitative data to evaluate the quality of prescribing. Antibiotic consumption significantly decreased between 2018 and 2022, particularly during the coronavirus disease 2019 (COVID-19) pandemic, despite a slight increase in 2022. During the study period, the most used antibiotic classes were penicillins (61.9% in 2022) followed by cephalosporins (10.5%), macrolides-lincosamides-streptogramins (7.3%) then fluoroquinolones (7.0%). Amoxicillin-clavulanic acid was the most consumed antibiotic; amoxicillin and ceftriaxone ranked second and third. Azithromycin consumption increased from 2020, as did the indicator regarding broad-spectrum antibiotics. The decreasing trend in antibiotic use and control of fluoroquinolone use over the study period suggest compliance with antibiotic use guidelines. However, changes in the use of broad-spectrum antibiotics and the substantial use of amoxicillin-clavulanic acid, although it is rarely a first-line antibiotic, highlight the need for antimicrobial stewardship activities and the usefulness of antibiotic consumption surveillance to identify priorities.

Three-Year Point Prevalence Survey of Antimicrobial Use in a Chinese University Hospital.

To evaluate the prevalence and quality of antimicrobial prescriptions using a Global Point Prevalence Survey (PPS) tool and help identify targets for improvement of antimicrobial prescribing and inform the development of antimicrobial stewardship activities. Antimicrobial prescriptions for inpatients staying at a hospital overnight were surveyed on one weekday in October 2018, November 2019, and November 2020. Data including basic patient information, antimicrobial drugs, quality evaluation of antimicrobial drug prescription, and the risk factors of nosocomial infection were collected from doctor network workstation. Patient information was anonymized and entered in the PPS Web application by physicians. A total of 720 patients (median age, 62 years) were surveyed. Of them, 246 (34.2%) were prescribed antimicrobials on the survey days. Hospital-wide antimicrobial use had a significantly decreasing trend (P < 0.001). The most commonly prescribed antimicrobial drugs were third-generation cephalosporins (40.5%), followed by quinolones (21.8%) and second-generation cephalosporin (12.5%). In our study, cefoperazone/sulbactam, ceftazidime, and levofloxacin were the most commonly used antimicrobials. The most common indication for antimicrobial use was pneumonia or lower respiratory tract infection (159/321, 49.5%). Antimicrobial for surgical prophylaxis represented 16.2% of the total antibiotic doses. Of those, 67.3% were administered for more than 24 h. The rate of adherence to antibiotic guidelines was 61.4%. The indications for antimicrobials were not documented in 54.5% of the prescriptions. Stop/review date was documented for 36.8% of prescriptions. The PPS tool is useful in identifying targets to enhance the quality of antimicrobial prescriptions to improve the adherence rate in hospitals. This survey can be used as a control to assess the rational application quality of antimicrobial after regular application of antimicrobial intervention.

The role of medicines and therapeutics committees structure in supporting optimal antibacterial use in hospitals in Uganda: A mixed method study.

Although the roles of Medicines and therapeutic committees (MTCs) have been expanding, there is limited information on the role of their structure in optimal antibacterial use in hospitals, especially in low-and-middle-income countries. Our study explored the structure and role of MTC in supporting antibacterial use in regional referral, general hospitals and tertiary private not-for-profit (PNFP) hospitals in Uganda. We conducted an explanatory sequential mixed-method approach with triangulation to explore the structure and functional role of MTCs from August 2019 to February 2020 in hospitals in Uganda. Quantitative data was collected using an interviewer-administered questionnaire among chairpersons or secretaries of MTCs and was analysed using descriptive statistics. We conducted key informant interviews using an interview guide among long-term serving members of MTCs to collect qualitative data which triangulated the quantitative data. The study revealed that sixteen hospitals had successfully established MTCs with an average duration of the MTCs' existence of 5.6 (+2.7) years. The membership of the MTCs varied between 7 and 14, with a median value of 10, and the majority of members in MTCs were pharmacists (15 out of 16) and clinical specialists (13 out of 16). The most frequent subcommittees of the 16 hospitals MTC were supply chain (n = 14), antimicrobial stewardship (n = 13), and infection control (n = 12). Majority (14 out of 16) of the MTCs supported availability and access of antibacterial use by selecting and evaluating antibacterials agents for their formulary lists using established criteria. Additionally, 15 out 16 MTCs conducted antimicrobial stewardship activities to support optimal antimicrobial use. In our study, MTC membership and subcommittees were critical structural components that aided the selection and evaluation antibacterials on hospital formulary lists and they supported optimal antibacterial use through implementing various antimicrobial stewardship activities. There is a need for the Ministry of Health to conduct more training on operationalising MTCs structures in all hospitals.

1664. The Impact of Levofloxacin Prophylaxis on Empiric Intravenous Antibiotic Use in Pediatric Hematopoietic Stem Cell Transplant Recipients

Abstract Background Clinical trials have demonstrated that levofloxacin prophylaxis during periods of neutropenia in hematopoietic stem cell transplantation (HSCT) reduces the frequency of bacteremia in adults and febrile episodes in children. Therefore, levofloxacin prophylaxis may also have a role in reducing empiric intravenous antibiotic (EIA) use. Methods This retrospective review assessed the impact of levofloxacin prophylaxis for patients &amp;lt; 18 years undergoing HSCT at a Canadian children’s hospital. The primary outcome was antibiotic days of therapy (DOT) during the pre-engraftment period comparing the pre-levofloxacin era (Jan 1, 2019–Jun 30, 2020) to the levofloxacin era (Jul 1, 2020–Dec 31, 2021). Patients were excluded if they were receiving EIA at the time of transplant, received chimeric antigen receptor T-cell therapy, or if levofloxacin use was discordant with their era. Secondary outcomes included the number of positive blood cultures and clinical deterioration episodes (clinical change resulting in blood culture draw and initiation/change of EIA). Results Fifty-four of 152 patients (36.5%) and 55 of 147 patients (37.4%) were included in the pre-levofloxacin and levofloxacin eras respectively. The most common reasons for exclusion were EIA use at the time of transplant and levofloxacin use discordant with the patient's era (Figure 1). Baseline characteristics were not significantly different between groups (Table 1). Mean DOT/pre-engraftment days (%) were significantly lower in the levofloxacin era for piperacillin-tazobactam (53.3 vs. 38.3, p=0.004) and amikacin (1.7 vs. 0.1, p=0.03), while there was no significant difference for meropenem, vancomycin, or all other antibiotics combined. There was also no significant difference in the number of positive blood cultures (11 vs. 7, p=0.35) or clinical deterioration episodes (55 vs. 66, p=0.1). Conclusion Levofloxacin prophylaxis in children undergoing HSCT reduced percent pre-engraftment days on piperacillin-tazobactam and amikacin, with no significant impact on the number of positive blood cultures or clinical deterioration episodes. Therefore, levofloxacin prophylaxis may facilitate antimicrobial stewardship activities through reduced use of certain broad-spectrum antibiotics. Disclosures Kathryn E. Timberlake, PharmD, Avir Pharma: Advisor/Consultant

Tackling antimicrobial resistance in primary care facilities across Pakistan: Current challenges and implications for the future

Antibiotics are gradually becoming less effective against bacteria worldwide, and this issue is of particular concern in economically-developing nations like Pakistan. We undertook a scoping review in order to review the literature on antimicrobial use, prescribing, dispensing and the challenges associated with antimicrobial resistance in primary care (PC) settings in Pakistan. Furthermore, this review aims to identify potential solutions to promote appropriate use of antimicrobials in Pakistan. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR) checklist, a comprehensive scoping review was conducted to review the literature of antimicrobials used, prescribed and dispensed in PC settings in Pakistan. Google Scholar and Pub-Med were searched for the period 2000–2023. Papers were analyzed on the basis of eligibility i.e., included antimicrobial use, prescribing and dispensing practices by general population at homes, by prescribers in outpatient departments of hospitals and by pharmacists/dispensers in community pharmacies, respectively. Two researchers analyzed the articles thoroughly and disagreements were resolved through discussion with a third reviewer. Both quantitative and qualitative research studies were eligible for inclusion. Additionally, the selected papers were grouped into different themes. We identified 4070 papers out of which 46 studies satisfied our eligibility criteria. The findings revealed limited understanding of antimicrobial resistance (AMR) by physicians and community pharmacists along with inappropriate practices in prescribing and dispensing antibiotics. Moreover, a notable prevalence of self-medication with antibiotics was observed among the general population, underscoring a lack of awareness and knowledge concerning proper antibiotic usage. Given the clinical and public health implications of AMR, Pakistan must prioritize its policies in PC settings. Healthcare professionals (HCPs) need to reduce inappropriate antibiotic prescribing and dispensing, improve their understanding of the AWaRe (access, watch and reserve antibiotics) classification and guidance, monitor current usage and resistance trends, as well as implement antimicrobial stewardship (ASP) activities starting in targeted locations.

Antimicrobial IV to PO switch practices at 9 institutions in Kentucky with Established Antimicrobial Stewardship Programs

Context Intravenous (IV) to oral (PO) transition of antimicrobial therapy is a common antimicrobial stewardship activity. Inpatient institutions seeking to create new IV to PO switch services or enhance existing services may benefit from a review of practices utilized at other institutions. Objective The objective of this review is to summarize IV to PO switch practices utilized by healthcare institutions with established antimicrobial stewardship programs across Kentucky. Methods The Kentucky Antimicrobial Stewardship Innovation Consortium (KASIC) invited pharmacists on the Advisory Board to share current IV to PO switch practices utilized at their institutions. The submitted documents were evaluated in a systematic approach and summarized. Results Nine of ten institutions represented by the Advisory Board submitted an IV to PO switch practice document for analysis. All institutions utilized pharmacist-driven protocols to allow automatic conversion from IV to PO for select antimicrobials based on specific patient criteria. All protocols included the following antimicrobials eligible for conversion: azithromycin, doxycycline, fluconazole, levofloxacin, linezolid, and metronidazole. Majority of protocols also had inclusion and exclusion criteria based on patient specific factors such as ability to use the enteral route, clinical stability, and infection type. There was variation in the level of restriction placed on conversion eligibility criteria among protocols. Conclusion IV to PO switch practices for antimicrobials vary across the state of Kentucky. Institutions should tailor protocols based on specific needs, clinical leadership support, and feasibility of implementation.

Antibiotic prescribing in remote versus face-to-face consultations for acute respiratory infections in primary care in England: an observational study using target maximum likelihood estimation

The COVID-19 pandemic has led to an ongoing increase in the use of remote consultations in general practice in England. Although the evidence is limited, there are concerns that the increase in remote consultations could lead to more antibiotic prescribing. In this cohort study, we used patient-level primary care data from the Clinical Practice Research Datalink to estimate the association between consultation mode (remote versus face-to-face) and antibiotic prescribing in England for acute respiratory infections (ARI) between April 2021 and March 2022. Eligibility criteria were applied at both practice-level and patient-level. 400 practices in England were sampled at random and then 600,000 patients were randomly sampled from the eligible patients (whose sex was recorded). Consultations for acute respiratory infections were identified. All antibiotic prescriptions were included, with the exception of antituberculosis drugs and antileprotic drugs, as identified through chapter 5.1 of the British National Formulary. The CPRD Aurum data was linked to the COVID-19 ONS infection survey by region. All analyses were done at the individual level. Repeated consultations from the same patient within 7 days were grouped together. We used targeted maximum likelihood estimation, a causal machine learning method with adjustment for infection type and patient-level, clinician-level and practice-level factors. There were 45,997 ARI consultations (34,555 unique patients) within the study period, of which 28,127 were remote and 17,870 were face-to-face. For children, 48% of consultations were remote and, for adults, 66% were remote. For children, 42% of remote and 43% of face-to-face consultations led to an antibiotic prescription; the equivalent values for adults were 52% and 42%, respectively. After adjustment with TMLE, adults with a remote consultation had 23% (odds ratio [OR] 1.23, 95% CI: 1.18-1.29) higher chance of being prescribed antibiotics than if they had been seen face-to-face. We found no significant association between consultation mode and antibiotic prescribing in children (OR 1.04 95% CI: 0.98-1.11). The higher rates of antibiotic prescribing in remote consultations for adults are cause for concern. We see no significant difference in antibiotic prescribing between consultation mode for children. These findings should inform antimicrobial stewardship activities for health-care professionals and policy makers. Future research should examine differences in guideline-compliance between remote and face-to-face consultations to understand the factors driving antibiotic prescribing in different consultation modes. None.

The Role of Adult Vaccines as Part of Antimicrobial Stewardship: A Scoping Review.

Antimicrobial resistance (AMR) is a significant global health concern, causing an estimated 700,000 deaths annually. Although immunisation has been shown to significantly reduce AMR, the role of vaccines as part of antimicrobial stewardship (AMS) practices is often overlooked. To identify and examine the available literature on the role of vaccines as part of AMS practices. A scoping review was conducted in the following databases: MEDLINE, Embase, Scopus, CINAHL, CCRCT, IPA, and WoS, along with grey literature sources. The review was conducted using the JBI Methodology for Scoping Reviews and reported in line with the PRISMA-SCr checklist. Among the 1711 records identified, 34 met the inclusion criteria; 8 discussed only the concept, while 26 discussed both the concept and the vaccine implementation method in AMS practices. There were eight recommended and/or utilised types of AMS activities identified involving vaccines, under four key themes of vaccine-related AMS strategies: Education, Screening, Vaccination, and Monitoring. Influenza and pneumococcal vaccines had the most evidence for inclusion. Overall, the evidence supports the role of vaccines as part of AMS practices and the value of their inclusion in creating improved and comprehensive AMS strategies to further combat the development of AMR.

Exploring drivers and challenges influencing antibiotic prescribing in outpatient settings and possible mitigation strategies in the United Arab Emirates: a qualitative study.

Healthcare institutions implement antimicrobial stewardship (AMS) programmes to optimize the use of antibiotics. The focus is often on inpatient rather than outpatient settings. We aimed to explore perceptions of AMS stakeholders on effective interventions for appropriate antibiotic use in outpatient settings, and the role of clinical pharmacists in the AMS multidisciplinary team. A qualitative semi-structured interview study using thematic analysis by two researchers independently. Participants that practice AMS programmes were recruited from healthcare facilities in the United Arab Emirates (UAE). Interviews were conducted face to face or online and transcribed verbatim. Four themes emerged: (i) Perceived factors leading to unnecessary or inappropriate antibiotic prescribing and their impact on patients and the community; (ii) current outpatient AMS activities and perceived barriers and facilitators for their sustainability; (iii) suggested outpatient AMS strategies to be implemented in outpatient settings; and (iv) perceived future AMS implementation barriers and suggested mitigation strategies. Several AMS interventions, together with the presence of a clinical pharmacist, may be effective in improving antibiotic use in UAE outpatient settings. Future research should investigate the most appropriate AMS strategy considering barriers and possible mitigation strategies to ensure sustainability.

An educational program on antimicrobial resistance and stewardship for staff nurses in a public tertiary care hospital in India.

Nurses, the largest group among healthcare professionals, hold a pivotal position to positively influence antimicrobial management by virtue of being in constant touch with patients and their widespread engagement in multiple activities relating to antimicrobial use. However, the existing gap in nursing curriculum particularly in areas related to antimicrobial resistance and optimal use of these agents limits the clinical application of nurses' skills and pose barrier to their contribution towards achieving desirable outcomes in patient care. This training program was conducted to increase the nurses' awareness on antimicrobial resistance (AMR) and sensitize them on their role in optimal antimicrobial management and stewardship activities. Training comprised of 4 modules focussing on topics like key concepts on antimicrobials, AMR, infection prevention and control, antibiotic allergy, optimal use of antibiotics and antimicrobial stewardship (AS). The participants' knowledge at baseline and 1 week after program were assessed. 190 nurses participated in the program. Post program there was a consistent increase in the number of correct responses to all knowledge-based questions pertaining to 4 modules. A significant improvement in knowledge scores for all modules from baseline was also seen. The participants rated the overall quality of program as very good and agreed on its applicability in their practice. The training program was quite successful in educating nurses on critical issues related to AMR and AS. Nurses need to be constantly trained and sensitized for their potential contributions in the field of AMR and stewardship.

Antimicrobial Stewardship Practices of Community Pharmacists in United Arab Emirates.

The purpose of this paper is to assess the implementation of antimicrobial stewardship (AMS) activities in community pharmacies in the United Arab Emirates (UAE). A descriptive cross-sectional study in the Emirate of Abu Dhabi, UAE, was conducted using a validated questionnaire. The questionnaire consisted of four AMS outpatient core elements, namely, commitment, action, tracking and reporting, and education and expertise, with each element containing different associated items. Pharmacy teams' responses were categorized into three levels: low, satisfactory, or high. Fifty-five pharmacy teams participated. Respondents confirmed implementation of at least one item of each AMS outpatient core element: commitment (94.5%), action (94.5%), tracking and reporting (67.3%), and education and expertise (81.8%). In supporting AMS implementation, surveyed teams scored high (81.8%) for action, satisfactory (65.5%) for education and expertise, low (43.6%) for tracking and reporting, and satisfactory (76.4%) for commitment. Attending antimicrobial stewardship programs was found to be a statistically significant predictor of implementation of antimicrobial stewardship activities (p = 0.048). The majority of community pharmacies met the core elements of outpatient antimicrobial stewardship to some degree. There is a significant association between participation in antimicrobial stewardship programs and implementation of antimicrobial stewardship activities by pharmacists in practice.

Antimicrobial Prescribing Preparedness of Croatian Medical Students-Did It Change between 2015 and 2019?

Antimicrobials are some of the most prescribed drugs by junior doctors, but studies suggest most medical graduates feel unprepared for their future prescribing tasks. The aim of the present study was to compare the self-reported preparedness to prudently prescribe antimicrobials of final-year medical students in Croatia in 2015 and 2019. The same self-reported web-based survey on the preparedness to prescribe antibiotics was used in both 2015 and 2019. All final-year students at all four medical schools in Croatia (Osijek, Rijeka, Split, and Zagreb) were invited to participate in both 2015 and 2019. Preparedness scores were divided into "topic preparedness scores" and "global preparedness scores". Topic preparedness scores represented the percentage of students at a medical school who felt sufficiently prepared for each topic. They were first established at a medical school level and then at the national level. Global preparedness scores were determined for each student separately and then calculated at the medical school and national levels. The country's global preparedness score, representing the average proportion of topics in which students felt sufficiently prepared, was slightly higher in 2015 compared with the 2019 results (62.7% vs. 56.5%; p = 0.191). Croatian students reported higher preparedness in 2015 than in 2019 for 25 out of 27 topics included in the survey. The majority of students reported a need for more education on antibiotic use both in 2015 and 2019 (78.0% vs. 83.0%; p = 0.199). Despite increasing antimicrobial stewardship activities in various healthcare settings, medical students who are about to start prescribing antibiotics on their own do not feel sufficiently prepared to do so. Antimicrobial stewardship programs should be designed to incorporate undergraduate medical student education, for instance, as a specific, mandatory course or integrated into other courses, such as clinical pharmacology.