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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 27  |  Issue : 1  |  Page : 54-58

Feasibility study of prospective audit, intervention and feedback as an antimicrobial stewardship strategy at the Lagos University Teaching Hospital


1 Department of Community Health and Primary Care, Faculty of Clinical Sciences, College of Medicine, University of Lagos, Lagos, Nigeria
2 Department of Paediatrics, Faculty of Clinical Sciences, College of Medicine, University of Lagos, Lagos, Nigeria
3 Department of Medical Microbiology and Parasitology, Faculty of Basic Medical Sciences, College of Medicine, University of Lagos, Lagos, Nigeria

Date of Submission02-Aug-2019
Date of Acceptance17-Dec-2019
Date of Web Publication14-Jan-2020

Correspondence Address:
Dr. Alero Ann Roberts
Department of Community Health and Primary Care, Faculty of Clinical Sciences, College of Medicine, University of Lagos, Lagos
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/npmj.npmj_115_19

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  Abstract 


Background: Antimicrobial resistance, a global problem, is mostly a consequence of misuse or overuse of antimicrobials. This study sought to audit the compliance to hospital antimicrobial policy and determine the ability of medical students to carry out audits.
Methodology: This was a retrospective study to determine compliance with departmental policies in the preceding 2 months in the Children's Emergency Room (ChER) using a checklist. The primary outcome was to determine the rational use of antibiotics. The secondary outcomes were to determine whether the de-escalation of antibiotic, change from intravenous to oral or change in prescriptions were performed in line with culture results based on the departmental policy.
Results: The records of 450 children who attended ChER of Lagos University Teaching Hospital in January and February 2018 were retrieved for this study, of which 279 (62.0%) were prescribed antimicrobials. A suspected or confirmed diagnosis of infection was made in 214 (76.6%) of the patients, significantly highest in the infant age group (P = 0.03). Cultures were taken from 94 patients (33.7%), and although not statistically significant, cultures were mostly taken from neonatal patients aged <28 days (20/49, 40.8%). Applying the criteria, compliance with departmental guidelines was found in 111 (39.8%) of the cases.
Conclusion: We found that the use of antimicrobials was judged unnecessary in 17.2% of the patients seen in ChER. There was a poor practice of collecting samples for culture before prescribing antibiotics. Prospective audit and feedback is feasible and it can be done with medical students who will report their findings to consultants and other doctors knowledgeable in principles of antimicrobial therapy.

Keywords: Antimicrobial stewardship, feasibility audit, feedback, intervention, Lagos


How to cite this article:
Roberts AA, Fajolu I, Oshun P, Osuagwu C, Awofeso O, Temiye E, Oduyebo O O. Feasibility study of prospective audit, intervention and feedback as an antimicrobial stewardship strategy at the Lagos University Teaching Hospital. Niger Postgrad Med J 2020;27:54-8

How to cite this URL:
Roberts AA, Fajolu I, Oshun P, Osuagwu C, Awofeso O, Temiye E, Oduyebo O O. Feasibility study of prospective audit, intervention and feedback as an antimicrobial stewardship strategy at the Lagos University Teaching Hospital. Niger Postgrad Med J [serial online] 2020 [cited 2020 Apr 1];27:54-8. Available from: http://www.npmj.org/text.asp?2020/27/1/54/275804




  Introduction Top


Antimicrobial resistance, a global problem, is mostly a consequence of misuse or overuse of antimicrobials.[1],[2] Data have shown high percentages of their use in our wards, and we need an intervention to reduce rates of prescribing antibiotics in our hospital. Antimicrobial stewardship (AMS) programmes have been set up in many institutions globally as a set of interventions that regulate and promote optimal use of antimicrobials to get the best clinical outcomes for patients while ensuring a reduction of the rate of developing resistance.[3],[4] Prospective audit with intervention and feedback is one of the two core evidence-based strategies of AMS,[5],[6] which depends on coordinated interventions by various medical professionals designed to ensure the appropriate use of antimicrobial agents by promoting the selection of optimal antibiotic drug regimen including dosing, duration of therapy and route of administration.

Prospective audit, as an intervention, involves a daily review of antimicrobial agents for appropriateness, and follow-up intervention involves contacting the prescribing physician to recommend alternative antimicrobial agents. It requires an antimicrobial committee to develop guidelines for appropriate use of targeted agents, and personnel are needed to perform the reviews and follow-up communication on a daily basis.[7],[8] Studies have documented a concept known as 'prescribing etiquette' which describes the dynamics between senior medical professionals, pharmacists and junior doctors. Often, within a hospital environment, the actions of junior doctors are under scrutiny, without fully recognising the complex social and clinical undercurrents that can influence prescribing patterns and behaviour.[9],[10] It has been documented that even when prescribers were unaware of any specific hospital policies, there was a pattern of prescribing that depended on the prevailing culture as well as treatment and clinical goals.[10] Prescribing habits once formed are difficult to change, and there is a value in inculcating good prescribing habits early on in the careers of medical professionals.[11],[12]

The aim of this retrospective study was to establish the level of compliance with the newly formulated hospital policy regarding the use of antimicrobials preceding the establishment of revised guidelines to be adopted in the paediatric department. This study also aimed to determine the ability of medical students to serve as audit assistants. The information obtained will be used to develop a prospective audit strategy relevant to the local context.


  Methodology Top


Lagos University Teaching Hospital (LUTH) is the largest tertiary health facility in Lagos with 761 beds, of which 179 are paediatric. The Children's Emergency Room (ChER) sees an average of 5260 cases a year. The paediatrics department had recently developed guidelines to rationalize the use of antimicrobials. This was a retrospective study to determine the appropriateness of antibiotics prescribed and was compliance with hospital antibiotic policies in the preceding 2 months in ChER using a checklist. The primary outcome was to establish whether the use of antibiotics was rational and within the recommendations of the departmental guidelines. The secondary outcomes were to determine whether the de-escalation of antibiotic, change from intravenous (IV) to oral or change in prescriptions were performed in line with culture results based on the departmental policy.

The admission register was used to identify the case notes of patients admitted to the ChER, which were retrieved and reviewed. Information about the patients' biodata obtained from the case notes were date of birth and date of presentation. From this, the age of the patient was calculated and reported as 'neonate' for those aged 0–28 days, 'infant' for those aged 29 days to 12 months and 'child' for those aged >12 months. Patient's gender, major presenting complaints and clinical diagnosis of infection were all noted and recorded. Types and sites of infections were recorded as diagnosed. Investigations ordered, antimicrobials prescribed – dose, route of administration and duration were also recorded.

Data analysis was done using Epi Info (version 7). Patients' ages and gender were reported as frequencies and percentages. Clinical diagnosis of infection was recorded as 'yes/no' and reported as frequencies and percentages. Antimicrobial use was classified as 'compliant (yes)/non-compliant (no)' based on:

  1. Cultures taken prior to institution of antimicrobial therapy
  2. Appropriateness based on guidelines
  3. Evidence of de-escalation of prescribed antimicrobials
  4. Stop/review date recorded in the case notes
  5. Appropriate route of administration
  6. Stated reasons for therapeutic/prophylactic antibiotics given
  7. Compliance with the hospital antibiotic policy.


Research assistants were the final year medical students of the College of Medicine, University of Lagos. They were trained on the newly developed departmental antibiotic guidelines and checklist and how to input the data using an electronic checklist which was forwarded to the unit consultants for the confirmation of accuracy and analysis of results.

Ethical approval was obtained from the HREC of LUTH; the principal researcher has CITI certification. Anonymity of the patients was maintained by avoiding the use of all identifiers in data collection.


  Results Top


The records of 450 children who attended ChER of LUTH in January and February 2018 were retrieved for this study, of which 279 (62.0%) were prescribed antimicrobials. Medical students were combed through the case notes retrieved and mine the information according to the checklist.

There was a slight preponderance of males (166/279, 59.5%), and the ages ranged from 2 h to 9 years. The mean age of the patients was 1.83 ± 2.15 years. Of the 279 prescriptions, 214 were for suspected or diagnosed infections, while 65 were assumed for prophylaxis. Two hundred and eight of 214 (97.2%) were for empiric therapy, while 6 (2.8%) were for targeted therapy [Table 1].
Table 1: Sociodemographic and clinical characteristics of patients (n=279)

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Diagnosis of infection

A suspected or confirmed diagnosis of infection was made in 214 (76.6%) of the patients, significantly highest in the infant age group (P = 0.03). Cultures were taken from 94 patients (33.7%), and although not statistically significant, cultures were mostly taken from neonatal patients aged <28 days (20/49, 40.8%). As shown in [Table 1], the diagnosis of infection was based on clinical judgement in 208 (97.2%) cases and supported by culture in 6 (2.8%) instances. Antibiotics were prescribed for prophylaxis in 65 (23.3%) cases, which was statistically significant among neonates and infants (P = 0.01). The most common infection diagnosed was sepsis in 107 (50.0%) cases, which was statistically significant in the neonates and infants (P = 0.0001). Clinical diagnosis of infection was enhanced with white blood cell counts in 106 (50.9%) cases but not with biomarkers.

The most commonly used route of administration was by an IV route in 191 (68.5%) cases, and again, statistically significant among the neonates and infants (P < 0.0001). An antibiotic prescription was judged necessary in 231 (82.8%) patients. In patients where the prescription was deemed necessary, the choice of antibiotic was appropriate based on guidelines in 231 (82.8%) patients. Applying the criteria, compliance with departmental guidelines was found in 111 (39.8%) cases [Table 2].
Table 2: Patterns of antimicrobial use

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  Discussion Top


This study reviewed the records of patients with the aim of establishing a baseline to compare the AMS prospective audit instituted and to determine the possibility of institutionalising medical students' participation for purposes of medical education and training. We found that the use of antimicrobials was judged unnecessary in 17.2% of the patients seen in ChER. Such substantial levels of unnecessary use of antimicrobials have been reported elsewhere as a potential threat to child survival, as the rates of community-acquired infections reduce and nosocomial bacteraemia emerges.[13] The prevalence of common ailments such as bronchopneumonia, perinatal asphyxia and sepsis with unknown focus was the most common admission diagnoses in children who received antibiotics in this study, in concordance with what has already been reported.[14],[15] The specific clinical diagnoses which required antimicrobial prophylaxis or therapy though noted will be further analysed in the planned prospective audit. It is, however, also pertinent to investigate why antimicrobials recommended in the guidelines were not appropriately prescribed.[16]

It is noteworthy that an attempt to confirm the diagnosis of infection by culture was made in less than half of the children with suspected bacterial infections placed on antimicrobials. While there is a need to investigate the reasons for this poor effort, it is good to promote laboratory diagnosis of infection in line with the departmental guidelines and hospital policy, as this would be in line with global standards.[17] The very poor practice of not collecting samples for culture before prescribing antibiotics is similar to the pattern reported in a six-site study in the US, which also noted that the practice of taking samples for cultures was not consistently carried out.[18] Other quality indicators of appropriate antibiotic prescribing were studied to identify areas that need attention and improvement in terms of rational antibiotic use. These included the use of IV route of administration, compliance with departmental antibiotic guidelines, de-escalation rates, the reason for prescription in notes and documentation of stop/review dates. This study documented that the most popular route of administration was the IV route, which was as high as 80.4%. However, after reviewing with the guidelines, IV route of administration was justified in all cases. Although this could be justified in neonatal cases, the guidelines require to be reviewed to further reduce the possibility of occurrence of adverse events from parenteral therapy.[19]

The reason for antibiotic prescription was documented in 76.5% of the case notes reviewed, but in over half, the choice of antibiotic prescribed was not in compliance with departmental antibiotic guidelines.[13] Even when the antibiotic was indicated, there was no stop/review date for 92% of antibiotics prescribed. In almost all patients, antibiotic use started out empirically and was de-escalated with culture results in only 2% of the patients. This extremely low practice of reviewing and de-escalating antimicrobials has been attributed to the lack of confidence on the part of prescribers in other studies, due in part to either lacking the relevant training, being junior in the profession or having to prescribe unsupervised.[20],[21] Put together, these data show an urgent need for an intervention, as well as the importance of embedding AMS practices in medical education.[22] Prospective audit with intervention and feedback is one of the two core evidenced-based strategies that have been proven to be effective in improving antibiotic use in hospitals, and in this retrospective study, the feasibility of prospective audit has been demonstrated.

Previous studies have identified the role that multiple systemic situations contribute to poor prescribing. These include inadequate written orders – prescription, documentation of stop orders and transcription and workload, patient factors and staff status – fatigue, interruptions and distractions during drug administration, all of which appear to be a problem here.[23] There is an effort internationally to institute responsible prescribing habits into doctors in training with an emphasis on review at 48 h with the aim to focus therapy on the narrower antibiotic spectrum and oral administration as much as possible.[24],[25] A documented review of the causes and factors associated with prescribing errors highlighted the significance of inadequate training and a reluctance to question senior colleagues.[26],[27] Previous research efforts have identified barriers of communication to the implementation and evaluation of prospective audits as a means of strengthening AMS. There have been efforts made to document the social determinants of appropriate prescribing behaviour. Studies have reported that a preferred means of communication was face-to-face personal communication, with no particular preference for the status of the person delivering the recommendation.[10],[28],[29],[30] Sufficient research evidence exists to underscore the importance of early and constant collaboration between the prescribing physicians and the AMS teams. Definitely, there is a case to be made for identifying good interpersonal relationships over rigid communication channels to obtain more effective patient management and improved outcomes.[31],[32],[33]

The paediatrics department in our hospital has initiated the development of guidelines for the responsible use of antimicrobials and adopted prospective audit and feedback as an intervention based on statements from the Society for Healthcare Epidemiology of America and the Paediatric Infectious Diseases Society.[8] Our paediatrics department was deemed to be the most responsive with respect to trialling the strategy of audit–feedback. An important aspect of this audit was to make sure that physicians' clinical decisions were evaluated against the present hospital policy and departmental guidelines to determine the areas where compliance was in breach.

It is clear that prospective audit and feedback is feasible in the Department of Paediatrics of the studied hospital and it can be done with medical students who will report their findings to consultants and other doctors knowledgeable in principles of antimicrobial therapy. The use of medical students who reported their findings to consultants both in paediatrics and in the AMS programme provided a distinct opportunity to strengthen training in AMS principles, use of guidelines within a context of clinical autonomy and intercollegiate communication. There are clear advantages in including medical students in auditing antibiotic use. One is that they will improve their knowledge and skills in the area of appropriate antimicrobial prescribing, making it easy to include this aspect of healthcare in the medical school curriculum. They also become able to help health-care personnel in this aspect of work, reducing their burden and relieving the barrier of inadequate staff to ensure good AMS.

Acknowledgements

We acknowledge with gratitude the committed assistance of the 500 level MBBS students of the College of Medicine, University of Lagos.

Financial support and sponsorship

This research was funded by the researchers.

Conflicts of interest

There are no conflicts of interest



 
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