A systematic review and narrative synthesis of pharmacist-led education-based antimicrobial stewardship interventions and their effect on antimicrobial use in hospital inpatients

Acknowledgements The authors would like to thank Dr Peerawat Jinathongthai and Dr Sisira Donsamak (Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Ubon Ratchathani University, Thailand) who advised and contributed in the literature search. Funding TM has received the Royal Thai Government Scholarship for his doctoral study (scholarship number ST G5397) at The University of Bath, Bath, UK. None of the other authors were funded by a specific grant for this research from any funding agency in the public, commercial, or non-for-profit sectors.Peer reviewedPostprin

Optimizing antibiotic prescribing in Nigerian hospitals

Background: Antimicrobial resistance (AMR) is a major concern facing global health today. It is severe in developing countries where the burdens of infectious diseases are much higher. Studies from developed countries suggest that antibiotic stewardship can improve antibiotic prescribing; however, these interventions are not directly applicable to developing countries. The aim of this study is to identify potentially feasible and effective strategies that will lead to improvements in antibiotic prescribing practices in hospitals in low and middle- income countries. Methods: A mixed methods approach was employed. First, a quantitative retrospective survey of antibiotic prescribing using patient’s case notes was conducted and then a qualitative prospective survey of prescribers and stakeholder’s perceptions of antibiotic prescribing. The qualitative survey employed semi-structured interviews to explore determinants of current antibiotic prescribing practices, suggestions to improve practice and the likely barriers. This study was carried out in four hospitals including two secondary and two tertiary care hospitals in Nigeria. Results: The results show that 72% of antibiotics were prescribed empirically. Only 28% of antibiotic prescriptions studied had complete compliance with the guidelines and relevant diagnostic tests were carried out in 15% of antibiotics prescriptions retrieved. Main determinants of current antibiotic prescribing practices include drug costs and availability, limited diagnostic resources and services, the excessive workload for healthcare providers, lack of policies/guidelines, and physicians’ attitudes. Recommendations prioritised by stakeholders for improvements to practice include provision of resources to support training and education, documentation and monitoring, improved diagnostic services and availability of antibiotics. Conclusion: This research extends our knowledge on antibiotic prescribing practices and strategies for implementing antibiotic stewardship programmes in resource poor settings. Establishing effective locally developed approaches can possibly improve antibiotic prescribing patterns. Achieving appropriate use and prescribing of antibiotics in Nigeria is a potentially achievable goal, provided the necessary resources are provided and funds allocated

Smoking cessation problem-based learning: Virtual experience

Background and Objectives: Problem-based learning (PBL) is a student-centered teaching and learning methodology where students collaboratively address specific issues. Tobacco use is a major health issue globally. Health professions and students need to have knowledge and skills to facilitate smoking cessation. The objective of this study is to assess feasibility of PBL during a virtual attachment involving institutions from Malaysia and the USA. Methods: A 4-week smoking cessation virtual attachment was conducted for three third-year University of Pittsburgh, USA pharmacy students. Malaysian smoking cessation experts designed and facilitated a PBL smoking cessation module. It was split into two 2-hour sessions with 3 triggers; Trigger 1: ‘Chief Presentation’, Trigger 2: ‘History & Motivational Interview’, and Trigger 3: ‘Brief 5A’s Intervention’. Students received Trigger 1 a day earlier and discussed amongst themselves. In session 1, Triggers 1-3 were given sequentially and discussed after completing all tasks from each trigger. In session 2 one-week later, facilitators gave formative assessment and students provided reflection regarding the PBL session. Upon completing the four-week virtual attachment, students provided feedback and facilitators graded the students. Result and Discussion: A comprehensive and interactive PBL session was successfully conducted virtually. Based on the clinical practice guidelines of both countries, there were differences in terms of availability and use of cessation medications, but the general principles of smoking cessation consultation and interventions were similar. Students were able to discuss the case openly, putting forth ideas and questions in both sessions. All students provided positive feedbacks regarding the PBL. Conclusions: With the extensive development of online platforms connecting the world over, student virtual attachment and mobility programmes can be easily conducted with minimal cost. A suitable module embedding PBL can be designed and conducted to best suit the online platform and the intended students

Smoking cessation problem-based learning: Virtual experience

Background and Objectives: Problem-based learning (PBL) is a student-centered teaching and learning methodology where students collaboratively address specific issues. Tobacco use is a major health issue globally. Health professions and students need to have knowledge and skills to facilitate smoking cessation. The objective of this study is to assess feasibility of PBL during a virtual attachment involving institutions from Malaysia and the USA. Methods: A 4-week smoking cessation virtual attachment was conducted for three third-year University of Pittsburgh, USA pharmacy students. Malaysian smoking cessation experts designed and facilitated a PBL smoking cessation module. It was split into two 2-hour sessions with 3 triggers; Trigger 1: ‘Chief Presentation’, Trigger 2: ‘History & Motivational Interview’, and Trigger 3: ‘Brief 5A’s Intervention’. Students received Trigger 1 a day earlier and discussed amongst themselves. In session 1, Triggers 1-3 were given sequentially and discussed after completing all tasks from each trigger. In session 2 one-week later, facilitators gave formative assessment and students provided reflection regarding the PBL session. Upon completing the four-week virtual attachment, students provided feedback and facilitators graded the students. Result and Discussion: A comprehensive and interactive PBL session was successfully conducted virtually. Based on the clinical practice guidelines of both countries, there were differences in terms of availability and use of cessation medications, but the general principles of smoking cessation consultation and interventions were similar. Students were able to discuss the case openly, putting forth ideas and questions in both sessions. All students provided positive feedbacks regarding the PBL. Conclusions: With the extensive development of online platforms connecting the world over, student virtual attachment and mobility programmes can be easily conducted with minimal cost. A suitable module embedding PBL can be designed and conducted to best suit the online platform and the intended students

Strategies to Improve Antimicrobial Utilization with a Special Focus on Developing Countries

From MDPI via Jisc Publications RouterHistory: accepted 2021-06-02, pub-electronic 2021-06-07Publication status: PublishedAntimicrobial resistance (AMR) is a high priority across countries as it increases morbidity, mortality and costs. Concerns with AMR have resulted in multiple initiatives internationally, nationally and regionally to enhance appropriate antibiotic utilization across sectors to reduce AMR, with the overuse of antibiotics exacerbated by the COVID-19 pandemic. Effectively tackling AMR is crucial for all countries. Principally a narrative review of ongoing activities across sectors was undertaken to improve antimicrobial use and address issues with vaccines including COVID-19. Point prevalence surveys have been successful in hospitals to identify areas for quality improvement programs, principally centering on antimicrobial stewardship programs. These include reducing prolonged antibiotic use to prevent surgical site infections. Multiple activities centering on education have been successful in reducing inappropriate prescribing and dispensing of antimicrobials in ambulatory care for essentially viral infections such as acute respiratory infections. It is imperative to develop new quality indicators for ambulatory care given current concerns, and instigate programs with clear public health messaging to reduce misinformation, essential for pandemics. Regular access to effective treatments is needed to reduce resistance to treatments for HIV, malaria and tuberculosis. Key stakeholder groups can instigate multiple initiatives to reduce AMR. These need to be followed up

Analysing the implementation of antibiotic stewardship policies in China: a study of the Nationwide Special Rectification Campaign on Hospital Antibiotic Use

China has been introducing antibiotic stewardship policies since the early 2000s to address the persistent and pervasive problem of irrational antibiotic use in hospitals. A recent set of antibiotic stewardship policies were set out between 2011 and 2013 in the Nationwide Special Rectification Campaign on Hospital Antibiotic Use (The Campaign). Drawing on implementation theories, this thesis examines the implementation of The Campaign in respect of factors pertinent to both its context and process, and how these factors interacted. The thesis is based on qualitative data gathered using indepth interviews and semi-structured interviews over two phases of fieldwork. Phase 1 analysed the perspectives of multiple actors at central (governmental organisations) and hospital levels (6 hospitals in urban Beijing, including a national tertiary hospital). Phase 2 – a case study focused on a single hospital – analysed the perspectives of actors from a typical secondary hospital in urban Shanghai. It was found that top-down implementation – characterised by clear line of accountability, target approach, punitive measures and redundancy of policies – was evident at both the central and hospital levels. However, The Campaign’s approach to focus on secondary and tertiary hospitals was strongly shaped by the organisation, delivery and financing of China’s healthcare system and its relevant reforms. Implementation at the hospital level was heavily influenced by contextual factors at system (healthcare system), organisation (hospital and clinical settings) and individual levels (prescribers and patients). Rational prescribing practices were driven in part by The Campaign’s interaction with some of those factors, but more crucially by frontline implementers’ active adaptation in response to the local context and needs. In recognising the potential of the top-down approach, the findings also highlight the need to better involve frontline implementers, align wholistic healthcare reforms and understand the complexity of policy interactions in the implementation of antibiotic stewardship

An investigation of the influence of a European formulary on general practitioner prescribing as part of an educational intervention

PhD ThesisThis thesis has addressedth e issue of primary care prescribing in different European countries. The first hypothesis investigated was: that the planned implementation of a multinational consensus-basedE uropean Formulary in primary care will result in more rational prescribing. A controlled trial involved 235 GPs from eight European countries with half the GPs participating in an educational intervention. This comprised dissemination of the Formulary and discussion of antibiotic and NSAID prescribing. Details of 101,544 doctor-patient consultations were collated and prescribing was compared and contrasted, before (Phase 1) and after the intervention (Phase 11), using performance indicators. This included measurement of the prescribing concordance with drugs recommended in the Formulary which increased by 2.9% (SEM 0.7) between Phases I to 11 in the intervention group and decreased by 1.3% (SEM 0.6) in the control group. This difference was found to be highly significant (p <0.001). Although some changes in clinical practice occurred, more notable differences were found in prescribing patterns between countries. A second hypothesis followed: that identification of the main influences on the participating GPs'prescribing will assist in the explanation of the varying effects of the Formulary in the different countries. A two-stage Delphi questionnaire study asked the GPs to identify the factors which they perceived to influence their prescribing and to rate their importance. The most important influences were drug related characteristics in six countries, followed by education/information and then patient factors. Pharmaceutical industrial factors were considered the least important influence in six countries, which followed regulatory factors in five countries. More influential factors appeared to be in the GPs' control, rather than ones imposed by national health care systems, regulation and government. The results show that the extent of Formulary adoption varied in different European countries. There remains a continuing place for the promotion of rational prescribing principally through education and information, including prescribing guidelines. Future initiatives may be more appropriate within countries but require adequate and sustained professional and government support