Systematic reviewSystematic review of factors promoting behaviour change toward antibiotic use in hospitals
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.
References (31)
- et al.
Attributable deaths and disability-adjusted life-years caused by infections with antibiotic-resistant bacteria in the EU and the European Economic Area in 2015: a population-level modelling analysis
Lancet Infect Dis
(2019) - et al.
What is antimicrobial stewardship?
Clin Microbiol Infect
(2017) - et al.
Current evidence on hospital antimicrobial stewardship objectives: a systematic review and meta-analysis
Lancet Infect Dis
(2016) - et al.
Comparison of antimicrobial stewardship programmes in acute-care hospitals in four European countries: a cross-sectional survey
Int J Antimicrob Agents
(2019) - et al.
Innovative tools for quality assessment: integrated quality criteria for review of multiple study designs (ICROMS)
Public Health
(2016) - et al.
Role of antimicrobial stewardship programmes in children: a systematic review
J Hosp Infect
(2018) - et al.
Integrating staff nurses in antibiotic stewardship: opportunities and barriers
Am J Infect Control
(2018) - et al.
The quality of studies evaluating antimicrobial stewardship interventions: a systematic review
Clin Microbiol Infect
(2019) - et al.
Optimizing design of research to evaluate antibiotic stewardship interventions: consensus recommendations of a multinational working group
Clin Microbiol Infect
(2020) - et al.
Antibiotic resistance: tools for effective translational research
Therapie
(2020)
Determinants of in-hospital antibiotic prescription behaviour: a systematic review and formation of a comprehensive framework
Clin Microbiol Infect
Global action plan on antimicrobial resistance
Estimating the burden of antimicrobial resistance: a systematic literature review
Antimicrob Resist Infect Control
A systematic review and meta-analysis of the effects of antibiotic consumption on antibiotic resistance
BMC Infect Dis
Eight habits of highly effective antimicrobial stewardship programs to meet the Joint Commission Standards for Hospitals
Clin Infect Dis
Cited by (3)
Implementation of an antimicrobial stewardship programme in three regional hospitals in the south-east of Liberia: lessons learned
2022, JAC-Antimicrobial Resistance