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Published on: August 30, 2018
Antimicrobial prescribing in French nursing homes and interventions for antimicrobial stewardship: a qualitative
Marie Hamard1,2,3, Claire Durand4, Laurène Deconinck5
1Department of Geriatrics, APHP Bichat Hospital, University Paris Cité, Paris, France. marie.hamard@aphp.fr.
Background:
Overuse of antibiotics is frequent in nursing homes (NHs) leading to adverse events and selection of resistant bacteria. Antimicrobial stewardship interventions showed heterogeneous effects on reducing inappropriate use of antimicrobials in NHs.
Objectives:
This study aimed (1) to analyze antimicrobial prescribing determinants in NHs; (2) to identify which resources for antimicrobial prescribing are used by NHs' physicians (3) understand which antimicrobial stewardship interventions are required and how they should be implemented in NHs.
Methods:
We conducted individual semi-directed interviews with NHs' prescribing physicians in Ile-de-France, France. A thematic content analysis was conducted iteratively.
Results:
Thirteen interviews were conducted. Participants were mostly women, with a median age of 48 years and a median professional experience in NHs of three years. Participants included medical coordinators, general practitioners and salaried physicians. Main determinants of antimicrobial prescribing in NHs were the perceived risk of infectious complications and discomfort in residents, the difficulty in obtaining microbiological samples and the lack of healthcare professionals to monitor patients. Most participants reported using national guidelines and electronic decision support systems to guide their antimicrobial prescribing. Institutional constraints accentuate situations of doubt and prompt physicians to prescribe antimicrobials "just in case" despite the will to follow guidelines and the known risks of antimicrobial misuse. Physicians stated that proper antimicrobial use in NHs would require a major effort but was not judged a priority as compared to other medical issues. Producing guidelines tailored to the NH's context, performing good practice audits with feedback on antimicrobial prescribing, and reinforcing multidisciplinary relationships and discussions between city and hospital professionals were cited as potential interventions. The role of the medical coordinator was described as central. According to physicians, collaboration among stakeholders, providing support and training during the process might prove effective strategies to ensure successful implementation.
Conclusion:
Antimicrobial prescribing is a complex decision-making process involving different factors and actors in NHs. Tailored guidelines, good practice audits, strengthened multidisciplinary collaboration were proposed as key AMS interventions. Physicians emphasized the central role of the medical coordinator supported by stakeholder engagement, collaboration, training and ongoing support for successful implementation.
Insights
Antibiotic prescribing in nursing homes is complex, influenced by perceived risks and institutional factors. Tailored guidelines and improved collaboration are key to effective antimicrobial stewardship interventions.
Area of Science:
- Geriatric Medicine
- Infectious Diseases
- Public Health
Background:
- Nursing homes frequently overuse antibiotics, contributing to adverse events and antibiotic resistance.
- Existing antimicrobial stewardship interventions have shown varied success in reducing inappropriate antimicrobial use in these settings.
Purpose of the Study:
- To analyze the factors influencing antimicrobial prescribing decisions in nursing homes.
- To identify the resources utilized by nursing home physicians for antimicrobial prescribing.
- To understand the necessary antimicrobial stewardship interventions and their optimal implementation strategies in nursing homes.
Main Methods:
- Conducted individual, semi-directed interviews with prescribing physicians in nursing homes in Ile-de-France, France.
- Employed an iterative thematic content analysis to interpret the interview data.
Main Results:
- Thirteen physicians participated, with diverse roles including medical coordinators and general practitioners.
- Key prescribing determinants included perceived risks of infection, difficulties in obtaining samples, and staffing shortages.
- Physicians utilized national guidelines and electronic decision support systems but often prescribed "just in case" due to institutional constraints.
- Interventions like tailored guidelines, practice audits, and enhanced multidisciplinary collaboration were suggested, with a central role for medical coordinators.
Conclusions:
- Antimicrobial prescribing in nursing homes is a multifaceted process involving various factors and stakeholders.
- Effective antimicrobial stewardship requires context-specific guidelines, practice audits, and strengthened collaboration.
- Physicians highlighted the crucial role of the medical coordinator, supported by stakeholder engagement, training, and ongoing support for successful intervention implementation.
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