A qualitative process evaluation of the introduction of procalcitonin testing as an antimicrobial stewardship intervention


Background Successful antimicrobial stewardship interventions are imperative in today’s environment of antimicrobial resistance. New antimicrobial stewardship interventions should include qualitative analysis such as a process evaluation to determine which elements within an intervention are effective and provide insight into the context in which the intervention is introduced. Objective To assess the implementation process and explore the contextual factors which influenced implementation. Setting An academic teaching hospital in Cork, Ireland. Methods A process evaluation was conducted on completion of a feasibility study of the introduction of a procalcitonin antimicrobial stewardship intervention. The process evaluation consisted of semi-structured face-to-face interviews of key stakeholders including participating (senior) doctors (5), medical laboratory scientists (3) and a hospital administrator. The Consolidated Framework for Implementation Research was used to guide data collection, analysis, and interpretation. Main outcome measures Qualitative assessment of the intervention implementation process, the contextual factors which influenced implementation and identification of improvements to the intervention and its implementation and determine if proceeding to a randomised controlled trial would be appropriate. Results Analysis of the interviews identified three main themes. (1) The procalcitonin intervention and implementation process was viewed positively to support prescribing decisions. Participants identified modifications to procalcitonin processing and availability to improve implementation and allow procalcitonin to be “more of a clinical influence”. (2) In the antimicrobial stewardship context the concept of fear of missing an infection and risks of potentially serious outcomes for patients emerged. (3) The hospital context consisted of barriers such as available resources and facilitators including the hospital culture of quality improvement. Conclusion This process evaluation provides a detailed analysis of the implementation of procalcitonin testing as an antimicrobial stewardship intervention. The positive findings of this process evaluation and feasibility study should be built upon and a full randomised controlled trial and economic evaluation should be conducted in a variety of hospital settings to confirm the effectiveness of procalcitonin as an antimicrobial stewardship intervention.

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  1. 1.

    World Health Organisation. Global action plan on antimicrobial resistance 2015. https://apps.who.int/iris/bitstream/handle/10665/193736/9789241509763_eng.pdf?sequence=1. Accessed 03.09.19.

  2. 2.

    Dellit TH, Owens RC, McGowan JE Jr, Gerding DN, Weinstein RA, Burke JP, et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis. 2007;44(2):159–77.

    Article  Google Scholar 

  3. 3.

    Ashiru-Oredope D, Sharland M, Charani E, McNulty C, Cooke J. Improving the quality of antibiotic prescribing in the NHS by developing a new Antimicrobial Stewardship Programme: Start Smart-Then Focus. J AntimicrobChemother. 2012;67(Suppl 1):i51–63.

    CAS  Google Scholar 

  4. 4.

    SARI Hospital Antimicrobial Stewardship Working Group. Guidelines for Antimicrobial Stewardship in Hospitals in Ireland. https://www.hpsc.ie/az/microbiologyantimicrobialresistance/infectioncontrolandhai/guidelines/File,4116,en.pdf. Accessed 30.08.19.

  5. 5.

    Davey P, Brown E, Charani E, Fenelon L, Gould IM, Holmes A, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev. 2013;30(4):CD003543.

    Google Scholar 

  6. 6.

    Davey P. The 2015 Garrod lecture: Why is improvement difficult? J AntimicrobChemother. 2015;70(11):2931–44.

    CAS  Google Scholar 

  7. 7.

    Michie S, van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci. 2011;6(42):42.

    Article  Google Scholar 

  8. 8.

    Davey P, Marwick CA, Scott CL, Charani E, McNeil K, Brown E, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev. 2017;2(2):CD003543.

    PubMed  Google Scholar 

  9. 9.

    Moore GF, Audrey S, Barker M, Bond L, Bonell C, Hardeman W, et al. Process evaluation of complex interventions: Medical Research Council guidance. BMJ. 2015;350(h1258):h1258.

    Article  Google Scholar 

  10. 10.

    Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M, et al. Developing and evaluating complex interventions: the new Medical Research Council guidance. BMJ. 2008;337(337):a1655.

    Article  Google Scholar 

  11. 11.

    Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355(26):2725–32.

    CAS  Article  Google Scholar 

  12. 12.

    Dixon-Woods M, Leslie M, Tarrant C, Bion J. Explaining Matching Michigan: an ethnographic study of a patient safety program. Implement Sci. 2013;8:70.

    Article  Google Scholar 

  13. 13.

    Kirk MA, Kelley C, Yankey N, Birken SA, Abadie B, Damschroder L. A systematic review of the use of the Consolidated Framework for Implementation Research. Implement Sci. 2016;11:72.

    Article  Google Scholar 

  14. 14.

    O’Neill J. Rapid diagnostics: stopping unnecessary use of antibiotics. London (UK) HM Government: 2015 https://amr-review.org/sites/default/files/Paper-Rapid-Diagnostics-Stopping-Unnecessary-Prescription-Low-Res.pdf. Accessed 03.09.19.

  15. 15

    Vollenweider DJ, Jarrett H, Steurer-Stey CA, Garcia-Aymerich J, Puhan MA. Antibiotics for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2012;12:CD010257.

    PubMed  Google Scholar 

  16. 16

    Wedzicha JAEC-C, Miravitlles M, Hurst JR, Calverley PM, Albert RK, Anzueto A, et al. Management of COPD exacerbations: a European Respiratory Society/American Thoracic Society guideline. Eur Respir. 2017;J49(3):1600791.

    Article  Google Scholar 

  17. 17.

    Schuetz P, Wirz Y, Sager R, Christ-Crain M, Stolz D, Tamm M, et al. Procalcitonin to initiate or discontinue antibiotics in acute respiratory tract infections. Cochrane Database Syst Rev. 2017;10(10):CD007498.

    PubMed  Google Scholar 

  18. 18.

    Schuetz P, Christ-Crain M, Thomann R, et al. Effect of procalcitonin-based guidelines vs. standard guidelines on antibiotic use in lower respiratory tract infections: the prohosp randomized controlled trial. JAMA. 2009;302(10):1059–66.

    CAS  Article  Google Scholar 

  19. 19.

    O’Riordan F, Shiely F, Byrne S, O’Brien D, Palmer B, Dahly D, et al. An investigation of the effects of procalcitonin testing on antimicrobial prescribing in respiratory tract infections in an Irish university hospital setting: a feasibility study. J AntimicrobChemother. 2019;74(11):3352–61.

    Google Scholar 

  20. 20.

    Davidoff F, Dixon-Woods M, Leviton L, Michie S. Demystifying theory and its use in improvement. BMJ QualSaf. 2015;24(3):228–38.

    Google Scholar 

  21. 21

    Tsalik EL, Petzold E, Kreiswirth BN, Bonomo RA, Banerjee R, Lautenbach E, et al. Advancing diagnostics to address antibacterial resistance: the diagnostics and devices committee of the antibacterial resistance leadership group. Clin Infect Dis. 2017;64(suppl_1):S41–S4747.

    CAS  Article  Google Scholar 

  22. 22.

    Branche AR, Walsh EE, Jadhav N, Karmally R, Baran A, Peterson DR, et al. Provider decisions to treat respiratory illnesses with antibiotics: insights from a randomized controlled trial. PLoS ONE. 2016;11(4):e0152986-e.

    Article  Google Scholar 

  23. 23.

    Cole JL. Provider perceptions on procalcitonin testing: a survey to tailor facility implementation. Infection. 2017;45(6):925–6.

    Article  Google Scholar 

  24. 24.

    O'Brien BC, Harris IB, Beckman TJ, et al. Standards for reporting qualitative research: a synthesis of recommendations. Acad Med. 2014;89(9):1245–51.

    Article  Google Scholar 

  25. 25.

    Report of the National Acute Medicine Programme. 2010 https://www.hse.ie/eng/services/publications/hospitals/amp.pdf. Accessed 03.09.19.

  26. 26.

    The Establishment of Hospital Groups as a transition to Independent Hospital Trusts, A report to the Minister for Health. https://health.gov.ie/wp-content/uploads/2014/03/IndHospTrusts.pdf.Accessed 03.09.19

  27. 27.

    Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009;4:50.

    Article  Google Scholar 

  28. 28.

    Nilsen P. Making sense of implementation theories, models and frameworks. Implement Sci. 2015;10(53):53.

    Article  Google Scholar 

  29. 29.

    Gale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med Res Methodol. 2013;13(1):117.

    Article  Google Scholar 

  30. 30.

    Ritchie J, Spencer L. Qualitative data analysis for applied policy research. In: Bryman A, Burgess RG, editors. Analyzing qualitative data. London: Routledge; 1994.

    Google Scholar 

  31. 31.

    Branche AR, Walsh EE, Vargas R, Hulbert B, Formica MA, Baran A, Peterson DR, Falsey AR. Serum procalcitonin measurement and viral testing to guide antibiotic use for respiratory infections in hospitalized adults: a randomized controlled trial. J Infect Dis. 2015;212(11):1692–700.

    CAS  Article  Google Scholar 

  32. 32

    Broom J, Broom A, Kirby E, Gibson AF, Post JJ. How do hospital respiratory clinicians perceive antimicrobial stewardship (AMS)? A qualitative study highlighting barriers to AMS in respiratory medicine. J Hosp Infect. 2017;96(4):316–22.

    CAS  Article  Google Scholar 

  33. 33.

    Broom J, Broom A, Kirby E. The drivers of antimicrobial use across institutions, stakeholders and economic settings: a paradigm shift is required for effective optimization. J AntimicrobChemother. 2019;74(9):2803–9.

    CAS  Google Scholar 

  34. 34

    Broom JK, Broom AF, Kirby ER, Gibson AF, Post JJ. Clinical and social barriers to antimicrobial stewardship in pulmonary medicine: a qualitative study. Am J Infect Control. 2017;45(8):911–6.

    Article  Google Scholar 

  35. 35

    Christensen I, Haug JB, Berild D, Bjørnholt JV, Jelsness-Jørgensen LP. Hospital physicians' experiences with procalcitonin—implications for antimicrobial stewardship; a qualitative study. BMC Infect Dis. 2020;20(1):515.

    Article  Google Scholar 

  36. 36

    Marshall M, De Silva D, Cruickshank L, Shand J, Wei L, Anderson J. What we know about designing an effective improvement intervention (but too often fail to put into practice). BMJ Qual Saf. 2017;26(7):578–82.

    Article  Google Scholar 

  37. 37.

    General Medical Council. Good medical practice. Manchester: GMC. Accessed at https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/good-medical-practice, 2013. Accessed 18.08.20.

  38. 38.

    Courts Service of Ireland. Annual report 2018. https://www.courts.ie/Courts.ie/library3.nsf/(WebFiles)/C2B4BFC1AFEC7B098025842D00473F25/$FILE/Courts%2520Service%2520Annual%2520Report%25202018.pdf. Accessed 23.08.19.

  39. 39.

    Comptroller T, General A. Managing the costs of clinical negligence in trusts. London: National Audit Office; 2017.

    Google Scholar 

  40. 40

    Krockow EM, Colman AM, Chattoe-Brown E, Jenkins DR, Perera N, Mehtar S, et al. Balancing the risks to individual and society: a systematic review and synthesis of qualitative research on antibiotic prescribing behaviour in hospitals. J Hosp Infect. 2019;101(4):428–39.

    CAS  Article  Google Scholar 

  41. 41

    Broom A, Gibson AF, Broom J, Kirby E, Yarwood T, Post JJ. Optimizing antibiotic usage in hospitals: a qualitative study of the perspectives of hospital managers. J Hosp Infect. 2016;94(3):230–5.

    CAS  Article  Google Scholar 

  42. 42.

    Voermans AM, Mewes JC, Broyles MR, Steuten LM. Cost-effectiveness analysis of a procalcitonin-guided decision algorithm for antibiotic stewardship using real-world US Hospital Data. Omics. 2019;23(10):508–15.

    CAS  Article  Google Scholar 

  43. 43

    Morgan DJ, Dhruva SS, Wright SM, Korenstein D. 2019 update on medical overuse: a review. JAMA Internal Med. 2019;179(11):1568–74.

    Article  Google Scholar 

  44. 44.

    Central Statistics Office of Ireland. Population and labour force projections 2017–2051. Accessed athttps://www.cso.ie/en/releasesandpublications/ep/p-plfp/populationandlabourforceprojections2017-2051/.Accessed 23.08.19.

  45. 45

    Shortell SM, Marsteller JA, Lin M, Pearson ML, Wu SY, Mendel P, Cretin S, Rosen M. The role of perceived team effectiveness in improving chronic illness care. Med Care. 2004;42(11):1040–8.

    Article  Google Scholar 

  46. 46

    Davidoff F, Batalden P, Stevens D, Ogrinc G, Mooney S. Publication guidelines for improvement studies in health care: evolution of the SQUIRE Project. Ann Intern Med. 2008;149(9):670–6.

    Article  Google Scholar 

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We wish to thank the interview participants for their help in conducting this study and interview participation.



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O’Riordan, F., Shiely, F., Byrne, S. et al. A qualitative process evaluation of the introduction of procalcitonin testing as an antimicrobial stewardship intervention. Int J Clin Pharm (2020). https://doi.org/10.1007/s11096-020-01159-1

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  • Antimicrobial stewardship
  • Consolidated framework for implementation research
  • Procalcitonin
  • Process evaluation
  • Respiratory tract infections