Impact of antimicrobial stewardship in critical care: a systematic review

Kaki, Reham; Elligsen, Marion; Walker, Sandra A N; Simor, Andrew E.; Palmay, Lesley; Daneman, Nick

doi:10.1093/jac/dkr137

Cited by 336 publications

(279 citation statements)

References 36 publications

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“…9,13,30,[156][157][158][159] Yet little has been written on the relevance of such interventions for doctors who are still undergoing training but are already required to make antimicrobial prescribing decisions in the clinical setting (for an example, see Brennan and Mattick 36 ). Given the widely recognised importance of social dynamics in driving prescribing behaviours, 34,35 the role of doctors in training deserves explicit attention, as they often need to manage power and teamwork dynamics along with their learning and career progression, in ways different from their senior colleagues.…”

Section: Summary Of Key Findingsmentioning

confidence: 99%

Interventions to improve antimicrobial prescribing of doctors in training (IMPACT): a realist review

Papoutsi

Mattick

Pearson

et al. 2018

Health Serv Deliv Res

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BackgroundInterventions to improve the antimicrobial prescribing practices of doctors have been implemented widely to curtail the emergence and spread of antimicrobial resistance, but have been met with varying levels of success.ObjectivesThis study aimed to generate an in-depth understanding of how antimicrobial prescribing interventions ‘work’ (or do not work) for doctors in training by taking into account the wider context in which prescribing decisions are enacted.DesignThe review followed a realist approach to evidence synthesis, which uses an interpretive, theory-driven analysis of qualitative, quantitative and mixed-methods data from relevant studies.SettingPrimary and secondary care.ParticipantsNot applicable.InterventionsStudies related to antimicrobial prescribing for doctors in training.Main outcome measuresNot applicable.Data sourcesEMBASE (via Ovid), MEDLINE (via Ovid), MEDLINE In-Process & Other Non-Indexed Citations (via Ovid), PsycINFO (via Ovid), Web of Science core collection limited to Science Citation Index Expanded (SCIE) and Conference Proceedings Citation Index – Science (CPCI-S) (via Thomson Reuters), Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, the Health Technology Assessment (HTA) database (all via The Cochrane Library), Applied Social Sciences Index and Abstracts (ASSIA) (via ProQuest), Google Scholar (Google Inc., Mountain View, CA, USA) and expert recommendations.Review methodsClearly bounded searches of electronic databases were supplemented by citation tracking and grey literature. Following quality standards for realist reviews, the retrieved articles were systematically screened and iteratively analysed to develop theoretically driven explanations. A programme theory was produced with input from a stakeholder group consisting of practitioners and patient representatives.ResultsA total of 131 articles were included. The overarching programme theory developed from the analysis of these articles explains how and why doctors in training decide to passively comply with or actively follow (1) seniors’ prescribing habits, (2) the way seniors take into account prescribing aids and seek the views of other health professionals and (3) the way seniors negotiate patient expectations. The programme theory also explains what drives willingness or reluctance to ask questions about antimicrobial prescribing or to challenge the decisions made by seniors. The review outlines how these outcomes result from complex inter-relationships between the contexts of practice doctors in training are embedded in (hierarchical relationships, powerful prescribing norms, unclear roles and responsibilities, implicit expectations about knowledge levels and application in practice) and the mechanisms triggered in these contexts (fear of criticism and individual responsibility, reputation management, position in the clinical team and appearing competent). Drawing on these findings, we set out explicit recommendations for optimal tailoring, design and implementation of antimicrobial prescribing interventions targeted at doctors in training.LimitationsMost articles included in the review discussed hospital-based, rather than primary, care. In cases when few data were available to fully capture all the nuances between context, mechanisms and outcomes, we have been explicit about the strength of our arguments.ConclusionsThis review contributes to our understanding of how antimicrobial prescribing interventions for doctors in training can be better embedded in the hierarchical and interprofessional dynamics of different health-care settings.Future workMore work is required to understand how interprofessional support for doctors in training can contribute to appropriate prescribing in the context of hierarchical dynamics.Study registrationThis study is registered as PROSPERO CRD42015017802.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

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Section: Summary Of Key Findingsmentioning

confidence: 99%

Interventions to improve antimicrobial prescribing of doctors in training (IMPACT): a realist review

Papoutsi

Mattick

Pearson

et al. 2018

Health Serv Deliv Res

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“…Nursing management started this soon after the study hospital had opened in response to a growing awareness of the need to manage ICU environments optimally, and provide safe care for patients. [4] Small community hospitals use antimicrobial therapy more frequently than large academic medical centres and are less likely to have AMS program mes in the acute-care setting. [11] The early detection of pathogens, appropriate use of antibiotics and reduction of healthcare-associated infections are essential in the care of the critically ill patient, and all ICUs should have AMS programmes that aim to ensure prompt, effective treatment.…”

Section: Organisational Rolementioning

confidence: 99%

“…This is especially important in an ICU, which has the highest proportion of patients vulnerable to infection and uses the most antibiotics in the hospital setting. [4] Research into the prevalence of infection in private and public ICUs in South Africa (SA) found that, in the private ICU sector, an inappropriate antibiotic was prescribed in 60.8% of patients, duration of administering an antibiotic was inappropriate in 81.7% of patients, and de-escalation was used in only 19.7% of patients. The authors attributed these figures to poor prescribing practices in this sector.…”

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confidence: 99%

Exploring the role of the ICU nurse in the antimicrobial stewardship team at a private hospital in KwaZulu-Natal, South Africa

Rout

Brysiewicz

2017

S Afr J Crit Care

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Background. Care of the critically ill patient has become increasingly challenging, with a rising incidence of resistant pathogens resulting in the ineffectiveness of many antibiotics. Severe infection is associated with prolonged intensive care unit (ICU) length of stay, and increased morbidity, mortality, and healthcare costs. Antimicrobial stewardship (AMS) aims to prevent resistance and protect patients and the wider community by promoting correct antimicrobial use. The current AMS literature has failed to describe the role of the ICU nurse in this important initiative. Objective. To explore the perceptions of AMS team members regarding the role of the ICU nurse in the AMS team. Methods. Using a qualitative research approach, purposive sampling was used to identify participants in an ICU. Semi-structured interviews were conducted with 15 participants, including ICU shift-leader nurses, nursing management, surgeons, anaesthetists, physicians, microbiologists and pharmacists. Data were analysed and categorised using content analysis. The study was conducted in a general ICU in the private healthcare sector in KwaZulu-Natal, South Africa. Results. Participants representing various disciplines of the AMS team felt that the role of the ICU nurse within the team was an important part of the AMS programme. Four categories that emerged from the data are discussed: organisational, advocacy, clinical and collaborative roles. Conclusion. The role of the ICU nurse was found to be essential to the success of AMS in the ICU. These findings provide implications for practice, which, if recognised and supported by all healthcare stakeholders from ICU and hospital management, could improve AMS in this acute care area. Globally, antimicrobial resistance has become one of the most important issues facing critical care. Resistance to antibiotics is escalating owing to overuse of antibiotics in the community and in hospitals, with increasing use of broad-spectrum antibiotics and delayed de-escalation practices.[1] Decreasing availability of antimicrobial therapy to treat complicated infections is attributed to the growing ineffectiveness of these medications due to increasing resistance, and the move of the pharmaceutical industry away from research and development of these products.[2] Therefore, it is becoming more difficult to manage infections in the very ill patient, resulting in prolonged intensive care unit (ICU) stay and increased mortality. [3] Antimicrobial stewardship (AMS) has developed as a proactive healthcare initiative to reduce antibiotic-selective pressure by promoting appropriate use of antimicrobial therapy and effective infection control. This is especially important in an ICU, which has the highest proportion of patients vulnerable to infection and uses the most antibiotics in the hospital setting.[4] Research into the prevalence of infection in private and public ICUs in South Africa (SA) found that, in the private ICU sector, an inappropriate antibiotic was prescribed in 60.8% of patients, duration of admi...

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“…Bununla birlikte, bazı CLSI sınır değerlerinin EUCAST sınır değerle-rinden farklı olduğu göz önüne alındığında, güncel epidemiyolojik verilerin eskileriyle karşılaştırılmasında hangi antibiyotiklerde değişik-lik bekleneceği bilinmeli, antibiyotiklere direnç artışı izlenirken bu konu göz önünde tutulmalı-dır. Doğru antibiyotik kullanımının direnç artışı-nı azaltacağı yapılan çalışmalarla kanıtlanmıştır (3) . Ülkemizin EUCAST standartlarına geçtiği bu dönemde iki rehber arasındaki direnç oranların-daki farklılıkların belirlenmesine gereksinim vardır.…”

Section: Introductionunclassified

Interpretation of Antibiotic Susceptibility Test Results of Pseudomonas aeruginosa, Acinetobacter baumannii and Escherichia coli Isolates According to EUCAST and CLSI: Hacettepe Experience

Maçin¹,

Yilmaz²,

Özden³

et al. 2017

TMCD

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Impact of antimicrobial stewardship in critical care: a systematic review

Cited by 336 publications

References 36 publications

Interventions to improve antimicrobial prescribing of doctors in training (IMPACT): a realist review

Interventions to improve antimicrobial prescribing of doctors in training (IMPACT): a realist review

Exploring the role of the ICU nurse in the antimicrobial stewardship team at a private hospital in KwaZulu-Natal, South Africa

Interpretation of Antibiotic Susceptibility Test Results of Pseudomonas aeruginosa, Acinetobacter baumannii and Escherichia coli Isolates According to EUCAST and CLSI: Hacettepe Experience

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