Systematic review
Systematic review of factors promoting behaviour change toward antibiotic use in hospitals

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Abstract

Background

Antimicrobial stewardship (AMS) programmes include actions to improve antibiotic use.

Objectives

This study aimed to identify factors of AMS interventions associated with behaviour change toward antibiotic use in hospitals, applying behavioural sciences.

Data sources

PubMed and Scopus online databases were searched.

Study eligibility criteria

Studies published between January 2015 and December 2020 were included. The required study outcomes were as follows: effect of the intervention reported in terms of antibiotic consumption, antibiotic costs, appropriateness of prescription, duration of therapy, proportion of patients treated with antibiotics, or time to appropriate antibiotic therapy.

Participants

Participants included health care professionals involved in antibiotic prescription and use in hospitals and patients receiving or susceptible to receiving antibiotics.

Interventions

Studies investigating AMS interventions in hospitals were included.

Methods

Risk of bias was determined using the integrated quality criteria for review of multiple study designs tool. A systematic review of AMS interventions was conducted using the behaviour change wheel to identify behaviour changes functions of interventions; and the action, actor, context, target, and time framework to describe how they are implemented. Relationships between intervention functions and the action, actor, context, target, and time domains were explored to deduce factors for optimal implementation.

Results

Among 124 studies reporting 123 interventions, 64% were effective in reducing antibiotic use or improving the quality of antibiotic prescription. In addition, 91% of the studies had a high risk of bias. The main functions retrieved in the effective interventions were enablement, environmental restructuring, and education. The most common subcategories were audit and feedback and real-time recommendation for enablement function, as well as material resources, human resources, and new tasks for environmental restructuring function. Most AMS interventions focused on prescriptions, targeted prescribers, and were implemented by pharmacists, infectious diseases specialists, and microbiologists. Interventions focusing on specific clinical situation were effective in 70% of cases.

Conclusions

Knowledge of factors associated with behaviour changes will help address local barriers and enablers before implementing interventions.

Introduction

The emergence and worldwide spread of antimicrobial resistance (AMR) is so alarming that tackling AMR has become a high priority for the World Health Organization [1]. In human medicine, AMR is associated with morbidity and mortality [2] and leads to prolonged hospital stay and increased health care costs [3]. One major driver of AMR is inappropriate use of antibiotics through the selection pressure mechanism [4]. Thus, improving antibiotic prescribing is a global emergency. Hospitals are particularly affected by AMR [2]: Inpatients generally present several risk factors, receive invasive care, and are often exposed to antibiotics for prophylaxis or treatment. Thus, improving antibiotic use in a hospital context is challenging [5].

Antimicrobial stewardship (AMS) has been defined as “a coherent set of actions which promote using antimicrobials responsibly” [6]. AMS programmes generally consist of organizational policy and practice-based interventions. AMS interventions improve appropriate antibiotic use and patient outcomes, reduce AMR- and health care–associated infections, and save health care costs [[7], [8], [9]]. However, variations in objectives and improvement strategies among hospitals and countries have been reported [6,10].

Indeed, improving antibiotic use is challenging because it depends on human factors within the context of a wide social network with continuous interactions among physicians, nurses, pharmacists, microbiologists, and patients. Behaviour change approaches are recommended to take into account psychological determinants [11] to optimize AMS interventions locally in hospitals and to maximize efficient implementation worldwide [1,7,[12], [13], [14]]. For example, interventions to change health care professional behaviours can be characterized with nine functions from the behaviour change wheel (BCW) [15]. This classification has already been used [7,16] to better describe AMS activities.

Furthermore, detailing the context for intervention implementation helps to clarify how it affects interventions effectiveness. The action, actor, context, target, time (AACTT) framework [17] proposes five domains to describe interventions [16,18]. Understanding intervention functions and context should help to identify barriers to and enablers of the implementation of successful AMS activities. Indeed, implementation science has been defined as the “scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice, and, hence, to improve health services” [19,20].

Previous literature reviews investigating appropriate antibiotic use in the hospital setting aimed to estimate the effectiveness and safety of interventions [[7], [8], [9]]. However, factors that make AMS interventions effective were not often precisely described. Considering that improvements in the reported outcomes regarding antibiotic use was the result of a change in health care professional behaviour, we conducted a systematic review to identify the most relevant factors that promote behaviour change toward antibiotic use in hospitals. We used behavioural sciences to identify the functions of AMS interventions related to changes in health care professional behaviours [15] and to describe how interventions are implemented [17].

Section snippets

Search strategy, data sources, and selection process

The Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were used to conduct this systematic review (Table S1) [21]. The review protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO CRD42021243939).

A systematic search was conducted electronically, using the PubMed and Scopus databases. The search included articles published from 01 January 2015 to 31 December 2020. The search strategy in PubMed combined the subject headings

Results

The electronic search retrieved 830 publications. We identified 63 potential additional publications from the reference lists of the included articles, resulting in a total of 875 publications after the removal of duplicates. Title and abstract screening resulted in 205 full texts to assess. Finally, 124 studies met the inclusion criteria for further analysis, reporting 123 AMS interventions (Fig. 1; Table S4).

Discussion

We conducted this systematic review to identify the conditions of implementation of AMS interventions and BCW intervention functions associated with improvement in antibiotic use. We described multimodal interventions involving multiple behaviours, and most were assessed as effective in reducing antibiotic use or improving the quality of antibiotic prescription. Potential publication bias and inclusion of studies with a high risk of bias must be considered when interpreting this finding.

When we

Conclusions

This review highlights relevant factors that should promote behaviour change toward antibiotic use in hospitals. Interventions including enablement, environmental restructuring, and education are likely to optimize antibiotic use. Taking into account the context, focusing on some subcategories of enablement and environmental restructuring could improve intervention effectiveness, such as performing real-time recommendations in interventions aimed at improving initial prescriptions. Therefore,

Author contributions

All authors have seen and approved the manuscript and contributed significantly to the work. All authors contributed equally to the study design, paper review, and data collection. E.P. performed the literature search, citation screening on title and abstract, full-text screening, data collection, data analysis, data interpretation, figure and table creation, wrote the first draft of the paper, and finalized the writing. C.D. and M.C. conceived the project, contributed to abstract and full-text

Transparency declaration

The authors declare that they have no conflicts of interest. There was no specific funding for this systematic review.

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