A complex ePrescribing-based Anti-Microbial Stewardship (ePAMS+) intervention for hospitals combining technological and behavioural components: protocol for a feasibility trial

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Abstract

Background

Antimicrobial resistance is a leading global public health threat, with inappropriate use of antimicrobials in healthcare contributing to its development. Given this urgent need, we developed a complex ePrescribing-based Anti-Microbial Stewardship intervention (ePAMS+).

Methods

ePAMS+ includes educational and organisational behavioural elements, plus guideline-based clinical decision support to aid optimal antimicrobial use in hospital inpatients. ePAMS+ particularly focuses on prompt initiation of antimicrobials, followed by early review once test results are available to facilitate informed decision-making on stopping or switching where appropriate. A mixed-methods feasibility trial of ePAMS+ will take place in two NHS acute hospital care organisations. Qualitative staff interviews and observation of practice will respectively gather staff views on the technical component of ePAMS+ and information on their use of ePAMS+ in routine work. Focus groups will elicit staff and patient views on ePAMS+; one-to-one interviews will discuss antimicrobial stewardship with staff and will record patient experiences of receiving antibiotics and their thoughts on inappropriate prescribing. Qualitative data will be analysed thematically. Fidelity Index development will enable enactment of ePAMS+ to be measured objectively in a subsequent trial assessing the effectiveness of ePAMS+. Quantitative data collection will determine the feasibility of extracting data and deriving key summaries of antimicrobial prescribing; we will quantify variability in the primary outcome, number of antibiotic defined daily doses, to inform the future larger-scale trial design.

Discussion

This trial is essential to determine the feasibility of implementing the ePAMS+ intervention and measuring relevant outcomes, prior to evaluating its clinical and cost-effectiveness in a full scale hybrid cluster-randomised stepped-wedge clinical trial. Findings will be shared with study sites and with qualitative research participants and will be published in peer-reviewed journals and presented at academic conferences.

Trial registration

The qualitative and Fidelity Index research were approved by the Health and Research Authority and the North of Scotland Research Ethics Service (ref: 19/NS/0174). The feasibility trial and quantitative analysis (protocol v1.0, 15 December 2021) were approved by the London South East Research Ethics Committee (ref: 22/LO/0204) and registered with ISRCTN ( ISRCTN 13429325) on 24 March 2022

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01230-w.

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Most cited references 20

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Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide

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Without a complete published description of interventions, clinicians and patients cannot reliably implement interventions that are shown to be useful, and other researchers cannot replicate or build on research findings. The quality of description of interventions in publications, however, is remarkably poor. To improve the completeness of reporting, and ultimately the replicability, of interventions, an international group of experts and stakeholders developed the Template for Intervention Description and Replication (TIDieR) checklist and guide. The process involved a literature review for relevant checklists and research, a Delphi survey of an international panel of experts to guide item selection, and a face to face panel meeting. The resultant 12 item TIDieR checklist (brief name, why, what (materials), what (procedure), who provided, how, where, when and how much, tailoring, modifications, how well (planned), how well (actual)) is an extension of the CONSORT 2010 statement (item 5) and the SPIRIT 2013 statement (item 11). While the emphasis of the checklist is on trials, the guidance is intended to apply across all evaluative study designs. This paper presents the TIDieR checklist and guide, with an explanation and elaboration for each item, and examples of good reporting. The TIDieR checklist and guide should improve the reporting of interventions and make it easier for authors to structure accounts of their interventions, reviewers and editors to assess the descriptions, and readers to use the information.

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Resistance to antibiotics is a major public-health problem and antibiotic use is being increasingly recognised as the main selective pressure driving this resistance. Our aim was to assess outpatient use of antibiotics and the association with resistance. We investigated outpatient antibiotic use in 26 countries in Europe that provided internationally comparable distribution or reimbursement data, between Jan 1, 1997, and Dec 31, 2002, by calculating the number of defined daily doses (DDD) per 1000 inhabitants per day, according to WHO anatomic therapeutic chemical classification and DDD measurement methodology. We assessed the ecological association between antibiotic use and antibiotic resistance rates using Spearman's correlation coefficients. Prescription of antibiotics in primary care in Europe varied greatly; the highest rate was in France (32.2 DDD per 1000 inhabitants daily) and the lowest was in the Netherlands (10.0 DDD per 1000 inhabitants daily). We noted a shift from the old narrow-spectrum antibiotics to the new broad-spectrum antibiotics. We also recorded striking seasonal fluctuations with heightened winter peaks in countries with high yearly use of antibiotics. We showed higher rates of antibiotic resistance in high consuming countries, probably related to the higher consumption in southern and eastern Europe than in northern Europe. These data might provide a useful method for assessing public-health strategies that aim to reduce antibiotic use and resistance levels.

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Author and article information

Contributors

Christopher J. Weir:

ORCID: http://orcid.org/0000-0002-6494-4903

Christopher.Weir@ed.ac.uk

Journal

Journal ID (nlm-ta): Pilot Feasibility Stud

Journal ID (iso-abbrev): Pilot Feasibility Stud

Title: Pilot and Feasibility Studies

Publisher: BioMed Central (London )

ISSN (Electronic): 2055-5784

Publication date (Electronic): 28 January 2023

Publication date PMC-release: 28 January 2023

Publication date Collection: 2023

Volume: 9

Electronic Location Identifier: 18

Affiliations

[1 ]GRID grid.4305.2, ISNI 0000 0004 1936 7988, Edinburgh Clinical Trials Unit, , Usher Institute, University of Edinburgh, ; Edinburgh, UK

[2 ]GRID grid.4305.2, ISNI 0000 0004 1936 7988, Usher Institute, University of Edinburgh, ; Edinburgh, UK

[3 ]GRID grid.420004.2, ISNI 0000 0004 0444 2244, Newcastle upon Tyne Hospitals NHS Foundation Trust, ; Newcastle, UK

[4 ]GRID grid.4305.2, ISNI 0000 0004 1936 7988, Institute for the Study of Science, Technology and Innovation, , University of Edinburgh, ; Edinburgh, UK

[5 ]GRID grid.5685.e, ISNI 0000 0004 1936 9668, Department of Health Sciences, , University of York, ; York, UK

[6 ]GRID grid.6572.6, ISNI 0000 0004 1936 7486, Institute of Clinical Sciences, , University of Birmingham, ; Birmingham, UK

[7 ]GRID grid.6572.6, ISNI 0000 0004 1936 7486, University of Birmingham, ; Birmingham, UK

[8 ]NHS Covid Vaccine North East and North Cumbria, Carlisle, UK

[9 ]GRID grid.451052.7, ISNI 0000 0004 0581 2008, NHS England, ; London, UK

[10 ]GRID grid.1006.7, ISNI 0000 0001 0462 7212, School of Pharmacy, , Newcastle University, ; Newcastle, UK

[11 ]GRID grid.7372.1, ISNI 0000 0000 8809 1613, Warwick Medical School, , University of Warwick, ; Coventry, UK

[12 ]GRID grid.5337.2, ISNI 0000 0004 1936 7603, School of Psychological Science, , University of Bristol, ; Bristol, UK

[13 ]GRID grid.5491.9, ISNI 0000 0004 1936 9297, School of Psychology, , University of Southampton, ; Southampton, UK

Author information

Christopher J. Weir http://orcid.org/0000-0002-6494-4903

Imad Adamestam https://orcid.org/0000-0002-2873-3682

Robin Williams https://orcid.org/0000-0002-9044-4611

Kathrin Cresswell https://orcid.org/0000-0001-6634-9537

Omara Dogar https://orcid.org/0000-0002-7122-8403

Sarah Pontefract https://orcid.org/0000-0002-0344-4075

Richard Lilford https://orcid.org/0000-0002-0634-984X

Ann Slee https://orcid.org/0000-0002-9731-7041

Antony Chuter https://orcid.org/0000-0002-0646-5939

Jillian Beggs https://orcid.org/0000-0002-7591-3256

Sarah Slight https://orcid.org/0000-0002-0339-846X

James Mason https://orcid.org/0000-0001-9210-4082

Aziz Sheikh https://orcid.org/0000-0001-7022-3056

Article

Publisher ID: 1230

DOI: 10.1186/s40814-022-01230-w

PMC ID: 9883604

PubMed ID: 36709308

SO-VID: bfd521c6-1b10-4f37-9b91-86008b7c1416

License:

Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

History

Date received : 23 May 2022

Date accepted : 16 December 2022

Funding

Funded by: FundRef http://dx.doi.org/10.13039/501100007602, Programme Grants for Applied Research;

Award ID: NIHR RP-PG-0617-20009

Award Recipient : Aziz Sheikh

Funded by: NIHR Applied Research Collaboration (ARC)-West

Funded by: NIHR HPRU for Behavioural Science and Evaluation

Funded by: FundRef http://dx.doi.org/10.13039/501100022419, National Institute for Health Research Southampton Biomedical Research Centre;

Custom metadata

Keywords: health informatics,bacteriology,infectious diseases,microbiology,decision support

Data availability:

Keywords: health informatics, bacteriology, infectious diseases, microbiology, decision support

A complex ePrescribing-based Anti-Microbial Stewardship (ePAMS+) intervention for hospitals combining technological and behavioural components: protocol for a feasibility trial

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Abstract

Background

Methods

Discussion

Trial registration

Supplementary Information

Related collections

Point-of-Care Testing for Infectious Diseases Super Collection

Most cited references 20

Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide

Understanding the mechanisms and drivers of antimicrobial resistance.

Outpatient antibiotic use in Europe and association with resistance: a cross-national database study.

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