'It makes life so much easier'-experiences of users of the MicroGuide™ smartphone app for improving antibiotic prescribing behaviour in UK hospitals: an interview study.

OBJECTIVES: To understand the impact on prescribing behaviour of an antimicrobial therapy guidelines smartphone app, in widespread use in hospitals in the UK. METHODS: Twenty-eight doctors and five nurse prescribers from four purposively selected hospitals in the UK participated in behavioural theory-informed semi-structured interviews about their experiences of using the MicroGuide™ smartphone app. Data were analysed using a thematic content analysis. RESULTS: Five themes emerged from the interview data: convenience and accessibility; validation of prescribing decisions; trust in app content; promotion of antimicrobial stewardship; and limitations and concerns. Participants appreciated the perceived convenience, accessibility and timesaving attributes of the app, potentially contributing to more prompt treatment of patients with time-critical illness. The interviewees also reported finding it reassuring to use the app to support decision-making and to validate existing knowledge. They trusted the app content authored by local experts and considered it to be evidence-based and up-to-date. This was believed to result in fewer telephone calls to the microbiology department for advice. Participants recognized the value of the app for supporting the goals of antimicrobial stewardship by promoting the responsible and proportionate use of antimicrobials. Finally, a number of limitations of the app were reported, including the risk of de-skilling trainees, cultural problems with using smartphones in clinical environments and software technical problems. CONCLUSIONS: The MicroGuide app was valued as a means of addressing an unmet need for updated, concise, trustworthy specialist information in an accessible format at the bedside to support safe and effective antimicrobial prescribing.

Measuring Appropriate Antibiotic Prescribing in Acute Hospitals: Development of a National Audit Tool Through a Delphi Consensus.

This study developed a patient-level audit tool to assess the appropriateness of antibiotic prescribing in acute National Health Service (NHS) hospitals in the UK. A modified Delphi process was used to evaluate variables identified from published literature that could be used to support an assessment of appropriateness of antibiotic use. At a national workshop, 22 infection experts reached a consensus to define appropriate prescribing and agree upon an initial draft audit tool. Following this, a national multidisciplinary panel of 19 infection experts, of whom only one was part of the workshop, was convened to evaluate and validate variables using questionnaires to confirm the relevance of each variable in assessing appropriate prescribing. The initial evidence synthesis of published literature identified 25 variables that could be used to support an assessment of appropriateness of antibiotic use. All the panel members reviewed the variables for the first round of the Delphi; the panel accepted 23 out of 25 variables. Following review by the project team, one of the two rejected variables was rephrased, and the second neutral variable was re-scored. The panel accepted both these variables in round two with a 68% response rate. Accepted variables were used to develop an audit tool to determine the extent of appropriateness of antibiotic prescribing at the individual patient level in acute NHS hospitals through infection expert consensus based on the results of a Delphi process.

Opportunities for antimicrobial stewardship in patients with acute bacterial skin and skin structure infections who are unsuitable for beta-lactam antibiotics: a multicenter prospective observational study.

PURPOSE: The objective of this prospective, observational study was to describe the treatment, severity assessment and healthcare resources required for management of patients with acute bacterial skin and skin structure infections who were unsuitable for beta-lactam antibiotic treatments. METHODS: Patients were enrolled across five secondary care National Health Service hospitals. Eligible patients had a diagnosis of acute bacterial skin and skin structure infection and were considered unsuitable for beta-lactam antibiotics (e.g. confirmed/suspected methicillin-resistant Staphylococcus aureus, beta-lactam allergy). Data regarding diagnosis, severity of the infection, antibiotic treatment and patient management were collected. RESULTS: 145 patients with acute bacterial skin and skin structure infection were included; 79% (n = 115) patients received greater than two antibiotic regimens; median length of the first antibiotic regimen was 2 days (interquartile range of 1-5); median time to switch from intravenous to oral antibiotics was 4 days (interquartile range of 3-8, n = 72/107); 25% (n = 10/40) patients with Eron class 1 infection had systemic inflammatory response syndrome, suggesting they were misclassified. A higher proportion of patients with systemic inflammatory response syndrome received treatment in an inpatient setting, and their length of stay was prolonged in comparison with patients without systemic inflammatory response syndrome. CONCLUSION: There exists an urgent need for more focused antimicrobial stewardship strategies and tools for standardised clinical assessment of acute bacterial skin and skin structure infection severity in patients who are unsuitable for beta-lactam antibiotics. This will lead to optimised antimicrobial treatment strategies and ensure effective healthcare resource utilisation.

Electronic prescribing system design priorities for antimicrobial stewardship: a cross-sectional survey of 142 UK infection specialists.

Background: The implementation of electronic prescribing and medication administration (EPMA) systems is a priority for hospitals and a potential component of antimicrobial stewardship (AMS). Objectives: To identify software features within EPMA systems that could potentially facilitate AMS and to survey practising UK infection specialist healthcare professionals in order to assign priority to these software features. Methods: A questionnaire was developed using nominal group technique and transmitted via email links through professional networks. The questionnaire collected demographic data, information on priority areas and anticipated impact of EPMA. Responses from different respondent groups were compared using the Mann-Whitney U -test. Results: Responses were received from 164 individuals (142 analysable). Respondents were predominantly specialist infection pharmacists (48%) or medical microbiologists (37%). Of the pharmacists, 59% had experience of EPMA in their hospitals compared with 35% of microbiologists. Pharmacists assigned higher priority to indication prompt ( P < 0.001), allergy checker ( P = 0.003), treatment protocols ( P = 0.003), drug-indication mismatch alerts ( P = 0.031) and prolonged course alerts ( P = 0.041) and lower priority to a dose checker for adults ( P = 0.02) and an interaction checker ( P < 0.05) than microbiologists. A 'soft stop' functionality was rated essential or high priority by 89% of respondents. Potential EPMA software features were expected to have the greatest impact on stewardship, treatment efficacy and patient safety outcomes with lowest impact on Clostridium difficile infection, antimicrobial resistance and drug expenditure. Conclusions: The survey demonstrates key differences in health professionals' opinions of potential healthcare benefits of EPMA, but a consensus of anticipated positive impact on patient safety and AMS.

Factors influencing Candida albicans growth in parenteral nutrition with and without lipid emulsion: using an established framework to inform maximum duration of infusion policy decisions.

BACKGROUND & AIMS: Because lipid putatively encourages contaminant growth it has been proposed that infusion of lipid-containing parenteral nutrition (PN) bags should be restricted to 24 h (48 h or longer if lipid free). This study aimed to examine this proposal by identifying factors affecting Candida albicans growth in PN. METHODS: C. albicans growth was assessed in quadruplicate in 12 PN infusates, with and without lipid and varying glucose concentrations. RESULTS: The results are presented as mean ± SEM. Baseline log10 colony forming units (cfu)/mL (1.806 ± 0.015) increased substantially by 48 h in the PN infusates (to 3.731 ± 0.059). In PN infusates (pH 6.14 ± 0.01) growth was unaffected by the presence of 5% w/v lipid (0.246 ± 0.156 log10 cfu/mL decrease; P = 0.127), and independently suppressed by increasing glucose concentration (0.438 ± 0.174 log10 cfu/mL decrease per 10% increase in w/v glucose; P = 0.018). In a separate analysis growth was suppressed by increasing energy density (0.520 ± 0.179 log10 cfu/mL decrease per 1000 kcal non-nitrogen energy in 2 L; P = 0.007), without a significant effect of % non-nitrogen energy from lipid (0.056 ± 0.036 log10 cfu/ml increase per 10%; P = 0.082). CONCLUSIONS: Using a framework developed to examine growth of potential contaminants in PN, the inclusion of lipid emulsion in PN produced no specific effect on the growth of C. albicans, other than by increasing energy density. Growth was independently suppressed by increasing either glucose concentration or non-nitrogen energy density.

Factors that influence Staphylococcus epidermidis growth in parenteral nutrition with and without lipid emulsion: a study framework to inform maximum duration of infusion policy decisions.

BACKGROUND & AIMS: Recommendations limit infusion of parenteral nutrition (PN) from bags with lipid to 24 h (48 h if lipid free) because lipid putatively encourages contaminant growth. This study aimed to examine these recommendations and identify factors affecting Staphylococcus epidermidis growth in PN. METHODS: S. epidermidis growth was assessed in quadruplicate in 12 PN regimens, with and without lipid and varying glucose concentrations. RESULTS: Baseline colony forming units (cfu)/mL (32.6) less than doubled at 48 h in all infusates. In PN infusates (pH 6.2 + 0.02 (SEM)) growth was independently increased by the presence of 5% w/v lipid (14.2 cfu/mL; P = 0.028), and glucose concentration (25.6 cfu/mL per 10% increase in w/v glucose; P = 0.003). In a separate analysis growth was stimulated by energy density (27.7 cfu/1000 kcal non-nitrogen energy in 2 L; P = 0.002), without a significant effect of % non-protein energy from lipid (-2.6 cfu/ml per 10%). CONCLUSIONS: Using a framework developed to examine growth of potential contaminants in PN, no evidence was found to support the specific recommendation to restrict the maximum infusion duration of lipid containing PN to a greater extent than lipid free PN. S. epidermidis growth was not only affected by the presence of lipid, but also glucose concentration and energy density.