Infection Control & Hospital Epidemiology (2019), 40,24–31 doi:10.1017/ice.2018.281
Original Article
A recipe for antimicrobial stewardship success: Using intervention mapping to develop a program to reduce antibiotic overuse in long-term care
Andrea Chambers PhD1, Sam MacFarlane RN1, Rosemary Zvonar BSc(Pharm)2, Gerald Evans MD1,3, Julia E. Moore PhD4, Bradley J. Langford PharmD1,5, Anne Augustin MLT, CIC1, Sue Cooper MLT, CIC1,
Jacquelyn Quirk MPH1, Liz McCreight CIC6 and Gary Garber MD1,2,7,8 1Public Health Ontario, Toronto, Ontario, Canada, 2The Ottawa Hospital and The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada, 3Department of Medicine, Queens University, Kingston, Ontario, Canada, 4The Center for Implementation, Toronto, Ontario, Canada, 5St. Joseph’s Health Centre, Toronto, Ontario, Canada, 6Mount Sinai Hospital, Toronto, Ontario, Canada, 7Department of Medicine, University of Toronto, Toronto, Ontario, Canada and 8Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
Abstract
Objective: To better understand barriers and facilitators that contribute to antibiotic overuse in long-term care and to use this information to inform an evidence and theory-informed program. Methods: Information on barriers and facilitators associated with the assessment and management of urinary tract infections were identified from a mixed-methods survey and from focus groups with stakeholders working in long-term care. Each barrier or facilitator was mapped to corresponding determinants of behavior change, as described by the theoretical domains framework (TDF). The Rx for Change database was used to identify strategies to address the key determinants of behavior change. Results: In total, 19 distinct barriers and facilitators were mapped to 8 domains from the TDF: knowledge, skills, environmental context and resources, professional role or identity, beliefs about consequences, social influences, emotions, and reinforcements. The assessment of barriers and facilitators informed the need for a multifaceted approach with the inclusion of strategies (1) to establish buy-in for the changes; (2) to align organizational policies and procedures; (3) to provide education and ongoing coaching support to staff; (4) to provide information and education to residents and families; (5) to establish process surveillance with feedback to staff; and (6) to deliver reminders. Conclusions: The use of a stepped approach was valuable to ensure that locally relevant barriers and facilitators to practice change were addressed in the development of a regional program to help long-term care facilities minimize antibiotic prescribing for asymptomatic bacteriuria. This stepped approach provides considerable opportunity to advance the design and impact of antimicrobial stewardship programs.
(Received 4 July 2018; accepted 28 September 2018; electronically published 5 November 2018)
Reducing unnecessary antibiotic use is an obvious target for public health intervention. Overuse and inappropriate use of antibiotics have been associated with antibiotic-resistant organ- isms, increased risk of Clostridium difficile infection, and other adverse drug reactions.1–5 One common target for antimicrobial stewardship programs is the treatment of asymptomatic bacter- iuria (ASB), defined as the presence of bacteria in the urine without clinical signs and symptoms of a urinary tract infection (UTI).7,8 Asymptomatic bacteriuria is common among residents in long-term care facilities (LTCFs),9 and antibiotics are often
Author for correspondence: Andrea Chambers, Public Health Ontario, 480 Uni-
versity Avenue, Suite 300, Toronto, ON, Canada, M5G 1V2. E-mail:
Andrea.Chaplin@
oahpp.ca
Cite this article: Chambers A, et al. (2019). A recipe for antimicrobial stewardship
success: Using interventionmapping to develop a program to reduce antibiotic overuse in long-term care. Infection Control & Hospital Epidemiology 2019, 40, 24–31. doi: 10.1017/ ice.2018.281
prescribed,6 despite strong evidence demonstrating no clinical benefit to treating ASB with antibiotics and guidelines discoura- ging this practice.10 A number of factors contribute to challenges in diagnosing
UTIs in LTCF residents, including communication difficulties and the presence of concurrent illnesses with associated non- specific symptoms.11–13 Nonspecific symptoms are often attrib- uted to a UTI and are used to guide treatment decisions,14 despite recommendations to the contrary.7,8 In addition, prescribing behaviors do not align with current evidence, and a number of complex factors contribute to the overtreatment of ASB. To support sustainable improvements in prescribing practices, anti- microbial stewardship programs should systematically address these complex factors contributing to the overtreatment of ASB. Although multipronged approaches are commonly employed to address ASB, the inclusion of multiple strategies does not necessarily mean better outcomes if the proposed strategies
© 2018 by The Society for Healthcare Epidemiology of America. All rights reserved. This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (
http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
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