Nudging In MicroBiology Laboratory Evaluation (NIMBLE): A scoping review

Abstract

Background:Nudging in microbiology is an antimicrobial stewardship strategy to influence decision making through the strategic reporting of microbiology results while preserving prescriber autonomy. The purpose of this scoping review was to identify the evidence that demonstrates the effectiveness of nudging strategies in susceptibility result reporting to improve antimicrobial use.Methods:A search for studies in Ovid MEDLINE, Embase, PsycINFO, and All EBM Reviews was conducted. All simulated and vignette studies were excluded. Two independent reviewers were used throughout screening and data extraction.Results:Of a total of 1,346 citations screened, 15 relevant studies were identified. Study types included pre- and postintervention (n = 10), retrospective cohort (n = 4), and a randomized controlled trial (n = 1). Most studies were performed in acute-care settings (n = 13), and the remainder were in primary care (n = 2). Most studies used a strategy to alter the default antibiotic choices on the antibiotic report. All studies reported at least 1 outcome of antimicrobial use: utilization (n = 9), appropriateness (n = 7), de-escalation (n = 2), and cost (n = 1). Moreover, 12 studies reported an overall benefit in antimicrobial use outcomes associated with nudging, and 4 studies evaluated the association of nudging strategy with subsequent antimicrobial resistance, with 2 studies noting overall improvement.Conclusions:The number of heterogeneous studies evaluating the impact of applying nudging strategies to susceptibility result reports is small; however, most strategies do show promise in altering prescriber’s antibiotic selection. Selective and cascade reporting of targeted agents in a hospital setting represent the majority of current research. Gaps and opportunities for future research identified from our scoping review include performing prospective randomized controlled trials and evaluating other approaches aside from selective reporting.

Antibiotic susceptibility reporting and association with antibiotic prescribing: a cohort study

“…These findings build on previous single-centre studies showing that suppressing specific urine culture and susceptibility results in hospitalized patients is associated with reduced antibiotic prescribing for asymptomatic bacteriuria [3,11] and reduced prescribing of targeted antibiotics such as fluoroquinolones [8]. Our study has confirmed this association between reporting and prescribing for both empirical and directed antibiotic prescribing, providing evidence to support selective reporting in a community setting.…”

“…Nudging is a term used to describe the concept of modifying choice architecture to augment decision-making without introducing incentives or inhibiting the autonomy of the decision maker [14]. Mounting evidence indicates that nudging is a promising intervention in the microbiology laboratory [8,15], but the lack of large-scale trials and specific guidance as well as insufficient resources have hindered its widespread implementation [7]. Future prospective trials and efforts to standardize selective reporting procedures may help to alleviate such challenges.…”

“…While national and international guidelines recommend the use of selective reporting [5,6], specific reporting policies are at the discretion of individual laboratories, resulting in a high degree of variability [7]. While individual studies have shown promising results of selective reporting in terms of reduced use of targeted antimicrobials, there is a lack of robust evidence evaluating the population-wide impact of selective reporting, particularly in outpatient settings [8].…”

Automated Susceptibility Testing With Vitek 2 Compared to MicroScan Reduces Vancomycin Alternative Therapy For Methicillin-Resistant Staphylococcus Aureus Bacteremia

“…First, leveraging microbiology reporting to improve anti-infective utilization has been well described. Antimicrobial nudging interventions involve persuasive language or strategic cascading of susceptibility results in the microbiology reports to influence prescribing behavior without limiting provider autonomy (Langford et al, 2019). This, and the aforementioned studies using Vitek 2, explore how reporting lower MICs may affect prescribing practices resulting in the use of less expensive drugs without worsening patient outcomes, though secondary endpoints were not adequately powered in this study.…”

Diagnostic Stewardship as a Team Sport: Interdisciplinary Perspectives on Improved Implementation of Interventions and Effect Measurement

“…The success of this intervention was further amplified using in-person and written education to ensure clinician adoption and understanding. Similar studies suggest that microbiology laboratory nudges and selective reporting effectively alter antimicrobial prescribing and optimize diagnostic test use [ 40 , 41 ]. Finally, for some diagnostics, evidence-based guidelines or protocols used at the point of care may help apply the microbiology results to clinical decision making and is therefore supported in the American Society for Clinical Pathology’s “Choosing Wisely” recommendations [ 42 ].…”