Understanding the Determinants of Antimicrobial Prescribing Within Hospitals: The Role of "Prescribing Etiquette"

Charani, Esmita; Castro‐Sánchez, Enrique; Sevdalis, Nick; Kyratsis, Yiannis; Drumright, Lydia N; Shah, Nisha; Holmes, Alison

doi:10.1093/cid/cit212

Cited by 383 publications

(374 citation statements)

References 39 publications

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“…'Prescribing etiquette,' that is, the reluctance to contradict prescriptions of colleagues and an inclination to follow the precedent of senior staff, is an embedded determinant of prescribing. [71][72][73] Consequentially, an unquestioning approach takes precedence over adherence to existing antibiotics policies, guidelines and advice. Few junior doctors feel empowered to question prescribing they feel to be inappropriate.…”

Section: The Bundles Of Carementioning

confidence: 99%

“…74 Current AMS programmes that target junior medical staff often fail to recognise the difficulties in challenging this ingrained cultural hierarchy. 71,72,74 As medical personnel value autonomy, 75 the success of AMS initiatives is maximised when developed within a framework of collaboration and collegiality. 76 Ultimately, for AMS to be effective, initiatives need the sustained endorsement of senior clinicians and engagement by the hospital leadership.…”

Section: The Bundles Of Carementioning

confidence: 99%

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Healthcare‐acquired infections: prevention strategies

Fernando

Gray

Gottlieb

2017

Internal Medicine Journal

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Healthcare‐acquired infections (HAI) impact on patient care and have cost implications for the Australian healthcare system. The management of HAI is exacerbated by rising rates of antimicrobial resistance (AMR). Health‐care workers and a contaminated hospital environment are increasingly implicated in the transmission and persistence of multi‐resistant organisms (MRO), as well as other pathogens, such as Clostridium difficile. This has resulted in a timely focus on a range of HAI prevention actions. Core components include antimicrobial stewardship, to reduce overuse and ensure evidence‐based antimicrobial use; infection prevention strategies, to control MRO – particularly methicillin‐resistant Staphylococcus aureus (MRSA), vancomycin‐resistant Enterococcus spp. (VRE) and, more recently, multi‐resistant Gram‐negative bacteria; enhanced institutional investment in hand hygiene; hospital cleaning and disinfection; and the development of prescribing guidelines and standards of care. AMR surveillance and comparisons of prescribing are useful feedback activities once effectively communicated to end users. Successful implementation of these strategies requires cultural shifts at local hospital level and, to tackle the serious threat posed by AMR, greater co‐ordination at a national level. HAI prevention needs to be multi‐modal, requires broad healthcare collaboration, and the strong support and accountability of all medical staff.

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Section: The Bundles Of Carementioning

confidence: 99%

Section: The Bundles Of Carementioning

confidence: 99%

Healthcare‐acquired infections: prevention strategies

Fernando

Gray

Gottlieb

2017

Internal Medicine Journal

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“…Qualitative studies on antimicrobial prescribing paid less attention to specific groups of prescribers, such as doctors in training. [31][32][33] With social norms and informal influences increasingly recognised as important in antimicrobial prescribing, 34,35 uncertainty exists about which intervention types to implement for trainees and what refinements are needed for local circumstances. There is also less understanding of how antimicrobial prescribing interventions should be tailored to address the specific needs of doctors in training, as most studies assume that doctors are a uniform body of health professionals with similar needs.…”

Section: Future Researchmentioning

confidence: 99%

“…Pharmacists, nurses, microbiologists and infectious diseases specialists are deemed important, especially when it comes to ratifying decisions against local practice, deciding on de-escalation or rationalisation, or clarifying details about dose and duration. 35,58,62,70 Realist analysis…”

Section: Interprofessional Influence and Supportmentioning

confidence: 99%

“…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%

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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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Behavioral Approach to Appropriate Antimicrobial Prescribing in Hospitals

et al. 2017

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IMPORTANCE Inappropriate antimicrobial prescribing leads to antimicrobial resistance and suboptimal clinical outcomes. Changing antimicrobial prescribing is a complex behavioral process that is not often taken into account in antimicrobial stewardship programs.OBJECTIVE To examine whether an antimicrobial stewardship approach grounded in behavioral theory and focusing on preserving prescriber autonomy and participation is effective in improving appropriateness of antimicrobial prescribing in hospitals. DESIGN, SETTING, AND PARTICIPANTSThe Dutch Unique Method for Antimicrobial Stewardship (DUMAS) study was a prospective, stepped-wedge, participatory intervention study performed from October 1, 2011, through December 31, 2015. Outcomes were measured during a baseline period of 16 months and an intervention period of 12 months. The study was performed at 7 clinical departments (2 medical, 3 surgical, and 2 pediatric) in a tertiary care medical center and a general teaching hospital in the Netherlands. Physicians prescribing systemic antimicrobial drugs for any indication for patients admitted to the participating departments during the study period were included in the study. INTERVENTIONSWe offered prescribers a free choice of how to improve their antimicrobial prescribing. Prescribers were stimulated to choose interventions with higher potential for success based on a root cause analysis of inappropriate prescribing.MAIN OUTCOMES AND MEASURES Appropriateness of antimicrobial prescriptions was determined using a validated approach based on guideline adherence and motivated guideline deviation and measured with repeated point prevalence surveys (6 per year). Appropriateness judgment was masked for the study period. Antimicrobial consumption was extracted from pharmacy records and measured as days of therapy per admission. We used linear and logistic mixed-model regression analysis to model outcomes over time.RESULTS A total of 1121 patient cases with 700 antimicrobial prescriptions were assessed during the baseline period and 882 patient cases with 531 antimicrobial prescriptions during the intervention period. The mean antimicrobial appropriateness increased from 64.1% at intervention start to 77.4% at 12-month follow-up (+13.3%; relative risk, 1.17; 95% CI, 1.04-1.27), without a change in slope. No decrease in antimicrobial consumption was found.CONCLUSIONS AND RELEVANCE Use of a behavioral approach preserving prescriber autonomy resulted in an increase in antimicrobial appropriateness sustained for at least 12 months. The approach is inexpensive and could be easily transferable to various health care environments.

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Understanding the Determinants of Antimicrobial Prescribing Within Hospitals: The Role of "Prescribing Etiquette"

Cited by 383 publications

References 39 publications

Healthcare‐acquired infections: prevention strategies

Healthcare‐acquired infections: prevention strategies

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

Behavioral Approach to Appropriate Antimicrobial Prescribing in Hospitals

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