Antimicrobial Stewardship

Céline Pulcini, Onder Ergonul, Fusun Can, Bojana Beović

• Publisher: Academic Press
• Year: 2017
• Print ISBN: 9780128104774
• eBook ISBN: 9780128134610
• Topic: Biological Sciences
• Subtopic: Microbiology
• Index: Biological Sciences

Antimicrobial Stewardship (AMS), Volume Two includes the experience of ESGAP workshops and courses on antibiotic stewardship since 2012. It combines clinical and laboratory information about AMS, with a focus on human medicine.The ESCMID study group on antibiotic policies (ESGAP) is one of the most productive groups in the field, organizing courses and workshops. This book is an ideal tool for the participants of these workshops.With short chapters (around 1500 words) written on different topics, the authors insisted on the following points: A 'hands on', practical approach, tips to increase success, a description of the most common mistakes, a global picture (out- and inpatient settings, all countries) and a short list of 10-20 landmark references.- Focuses on the most recent antimicrobial stewardship strategies- Provides a detailed description of laboratory support- Offers a balanced synthesis of basic and clinical sciences for each individual case, presenting clinical courses of the cases in parallel with the pathogenesis and detailed microbiological information for each infection- Describes the prevalence and incidence of the global issues and current therapeutic approaches- Presents the measures for infection control

Section B

AMS Strategies

Chapter 4

Improving Antimicrobial Prescribing

Input from Behavioral Strategies and Quality Improvement Methods

Marlies E.J.L. Hulscher*; Jeroen Schouten*^,** ^* Radboud University Medical Center, Nijmegen, The Netherlands
^** Canisius Wilhelmina Ziekenhuis, Nijmegen, The Netherlands

Abstract

From systematic reviews, it can be concluded that any behavioral stewardship intervention might work to improve professionals' antimicrobial use. This chapter provides guidance to professionals on how to select those interventions that might work best in a specific setting. Change models and theories derived from various disciplines and scientific areas suggest that behavior change is more likely to be successful if an assessment of the key drivers of current behavior informs the choice of the intervention. So, the challenge lies in systematically building an intervention on the careful assessment of determinants and on a coherent theoretical base while linking determinants to interventions, taking the lessons regarding the effectiveness of various behavioral interventions into account.

Keywords

Improvement; Antimicrobial use; Barriers and facilitators; Behavioral interventions

Stewardship Interventions

Antimicrobial stewardship is a key approach in the battle against antimicrobial resistance, both in terms of reducing the current burden and the further development and spread of resistance in the future. Through the years, various documents (guidelines, consensus statements, policy statements, etc.) have been published by national and international organizations that provide clear recommendations for developing stewardship programs. These documents often include recommendations on appropriate structural preconditions that should be met when embarking on stewardship, like the establishment of an antimicrobial stewardship team. In addition, they describe various stewardship interventions that can be applied by such teams when aiming at appropriate antimicrobial prescribing practices. Depending on local antimicrobial use, size, staffing, personnel, infrastructures, and available resources, different institutions may need different interventions to combat antimicrobial resistance. Antimicrobial stewardship can be thought of as a menu of interventions that can be designed and adapted to fit the infrastructure of any hospital [1].

Stewardship programs encompass two intrinsically different sets of interventions describing either the “what” or the “how” in stewardship programs. A first set of interventions describes recommended antimicrobial care interventions or antimicrobial prescribing practices that define “appropriate antimicrobial use” in hospital inpatients regarding indication, choice of drug, dose, route, or duration of treatment. Examples of such interventions are “switch from intravenous to oral antimicrobial therapy” or “streamline therapy” in individual patients when appropriate [2].

A second set of interventions describes interventions to ensure that professionals actually apply these prescribing practices in daily practice. These behavioral change interventions include many different interventions—like the provision of a formulary, prospective, or retrospective audit and feedback; educational meetings; reminders; financial interventions; or the revision of professional roles [3]—that all can be performed to improve appropriate antimicrobial prescribing practices. So, the second set of interventions is applied in professionals to ensure that the first set of interventions is appropriately applied in patients. These behavioral change interventions either directly or indirectly (through interventions targeting the system/organization) target the professional and, overall, restrict or guide toward the more effective professional use of antimicrobials. Table 1 provides more detail on various behavioral change interventions as described in the literature, in this case the Cochrane review of Davey et al. [4].

Table 1

Examples of Behavioral Change Interventions to Improve Antimicrobial Prescribing Practices in Daily Practice [3,4]

Persuasive interventions	• Audit and feedback, i.e., a summary of health workers' performance over a specified period of time, given to them in a written, electronic, or verbal format. The summary may include recommendations for clinical action. • Reminders, i.e., manual or computerized interventions that prompt health workers to perform an action during a consultation with a patient, for example, computer decision support systems. • Educational outreach, i.e., personal visits by a trained person to health workers in their own settings to provide information with the aim of changing practice. • Educational meetings and dissemination of educational materials • Formal or informal local consensus processes, for example, agreeing to a clinical protocol to manage a patient group, adapting a guideline for a local health system or promoting the implementation of guidelines.
Restrictive interventions	• Selective reporting of laboratory susceptibilities • Formulary restriction • Requiring prior authorization of prescriptions • Therapeutic substitution • Automatic stop orders • Antimicrobial cycling or rotation
Structural interventions	• Changing from paper to computerized records • Rapid laboratory testing • Computerized decision support systems • Introduction or organization of quality monitoring mechanisms

The definitions for audit and feedback, reminders, educational outreach, educational meetings and consensus processes are drawn verbatim from the following source, with permission: [Taken from Effective Practice and Organization of Care (EPOC). EPOC Taxonomy; 2015. Available at: https://epoc.cochrane.org/epoc-taxonomy and Davey P, Brown E, Charani E, Fenelon L, Gould IM, Holmes A, Ramsay CR, Wiffen PJ, WilcoxM. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database of Systematic Reviews 2013, Issue 4. Art. No: CD003543.]

In this chapter, the application of behavioral change interventions to improve appropriate antimicrobial use is viewed as an example of healthcare quality improvement. In this manner, stewardship refers to “coordinated interventions designed to continuously measure and improve the appropriate use of antimicrobial agents by promoting the selection of the optimal antimicrobial drug regimen including dosing, duration of therapy, and route of administration” [9]. Measurement is critical to identify opportunities for improvement and assess the impact of improvement efforts (see Boxes 1 and 2). For antimicrobial stewardship, measurement may involve the evaluation of both process (Are recommended prescribing practices being followed as expected?) and outcome (Have interventions improved patient or microbiological/ecological outcomes?).

Box 1

The Importance of Measurement of Antimicrobial Prescribi...

Table of contents

• Cover image
• Title page
• Table of Contents
• Copyright
• Contributors
• Foreword by Prof. Mario Poljak
• Introduction by Murat Akova
• Introduction by Jesús Rodríguez-Baño
• Introduction by Evelina Tacconelli
• Preface
• Acknowledgments
• Section A: The Global Picture of Antimicrobial Use and Resistance
• Section B: AMS Strategies
• Section C: AMS in Specific Clinical Settings
• Section D: AMS Experiences Around the World
• Section E: Research and Perspectives
• Index
• List of Abbreviations