Multifaceted antibiotic stewardship intervention using a participatory-action-research approach to improve antibiotic prescribing for urinary tract infections in frail elderly (ImpresU): study protocol for a European qualitative study followed by a pragmatic cluster randomised controlled trial

Abstract

IntroductionAlmost 60% of antibiotics in frail elderly are prescribed for alleged urinary tract infections (UTIs). A substantial part of this comprises prescriptions in case of non-specific symptoms or asymptomatic bacteriuria, for which the latest guidelines promote restrictiveness with antibiotics. We aim to reduce inappropriate antibiotic use for UTIs through an antibiotic stewardship intervention (ASI) that encourages to prescribe according to these guidelines. To develop an effective ASI, we first need a better understanding of the complex decision-making process concerning suspected UTIs in frail elderly. Moreover, the implementation approach requires tailoring to the heterogeneous elderly care setting.Methods and analysisFirst, we conduct a qualitative study to explore factors contributing to antibiotic prescribing for UTIs in frail elderly, using semi-structured interviews with general practitioners, nursing staff, patients and informal caregivers. Next, we perform a pragmatic cluster randomised controlled trial in elderly care organisations. A multifaceted ASI is implemented in the intervention group; the control group receives care as usual. The ASI is centred around a decision tool that promotes restrictive antibiotic use, supported by a toolbox with educational materials. For the implementation, we use a modified participatory-action-research approach, guided by the results of the qualitative study. The primary outcome is the number of antibiotic prescriptions for suspected UTIs. We aim to recruit 34 clusters with in total 680 frail elderly residents ≥70 years. Data collection takes place during a 5-month baseline period and a 7-month follow-up period. Finally, we perform a process evaluation. The study has been delayed for 6 months due to COVID-19 and is expected to end in July 2021.Ethics and disseminationEthical approvals and/or waivers were obtained from the ethical committees in Poland, the Netherlands, Norway and Sweden. The results will be disseminated through publication in peer-reviewed journals and conference presentations.Trial registration numberNCT03970356.

Decisions on antibiotic prescribing for suspected urinary tract infections in frail older adults: a qualitative study in four European countries

“…Multifaceted interventions, tailored to the specific setting may thus be more likely to succeed, as demonstrated previously [ 43 , 44 ]. Within our ImpresU-consortium, we used these interviews to design and tailor an ASI with a multifaceted educational toolbox, using a participatory action research approach for local adaptation [ 24 ].…”

“…This study informed the development and tailoring of an ASI that was implemented in a subsequent cluster randomised controlled trial. The protocol describing the design of this qualitative study and subsequent trial has been published previously [ 24 ]. The consolidated criteria for reporting qualitative research (COREQ) checklist is provided in Appendix 1 [ 30 ].…”

“…Preliminary findings were presented at the online General Practice Research on Infections Network conference (24 September 2021). The study design and protocol were previously published [ 24 ].…”

“…We therefore formed a European research consortium in Poland, the Netherlands, Norway and Sweden to improve antibiotic prescribing for UTIs in frail older adults (ImpresU) [ 24 ]. In these countries, organisation of care, guidelines and progress of antibiotic stewardship differ [ 25–29 ].…”

The value, challenges and practical considerations of conducting qualitative research on antimicrobial stewardship in primary care

“…In the initial stages, PPI input can ensure that the research topic is relevant and of importance to patients or public, 69 , 70 that methods are appropriate and recruitment materials understandable to the potential participants. 71 , 72 As the study progresses, PPI representatives can advise on identifying and optimizing recruitment strategies. 73 They might also act as gatekeepers for recruitment providing access to networks and newsletters, charities and other associations, which can be particularly beneficial.…”