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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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.
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.
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.
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.
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.
Davey P. The 2015 Garrod lecture: Why is improvement difficult? J AntimicrobChemother. 2015;70(11):2931–44.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Davidoff F, Dixon-Woods M, Leviton L, Michie S. Demystifying theory and its use in improvement. BMJ QualSaf. 2015;24(3):228–38.
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.
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.
Cole JL. Provider perceptions on procalcitonin testing: a survey to tailor facility implementation. Infection. 2017;45(6):925–6.
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.
Report of the National Acute Medicine Programme. 2010 https://www.hse.ie/eng/services/publications/hospitals/amp.pdf. Accessed 03.09.19.
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
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.
Nilsen P. Making sense of implementation theories, models and frameworks. Implement Sci. 2015;10(53):53.
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.
Ritchie J, Spencer L. Qualitative data analysis for applied policy research. In: Bryman A, Burgess RG, editors. Analyzing qualitative data. London: Routledge; 1994.
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.
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.
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.
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.
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.
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.
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.
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.
Comptroller T, General A. Managing the costs of clinical negligence in trusts. London: National Audit Office; 2017.
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.
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.
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.
Morgan DJ, Dhruva SS, Wright SM, Korenstein D. 2019 update on medical overuse: a review. JAMA Internal Med. 2019;179(11):1568–74.
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.
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.
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.
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
- Antimicrobial stewardship
- Consolidated framework for implementation research
- Process evaluation
- Respiratory tract infections