Behavioural approaches to optimise antibiotic stewardship in hospitals

Antibiotic stewardship is a key strategy to prevent antibiotic resistance and reduce healthcare associated infections. There is robust evidence to show that a variety of stewardship interventions are effective in reducing unnecessary treatment safely, without increase in mortality. However, stewardship efforts require health professionals to change their behaviour and it is uncertain the extent to which the substantial theoretical and empirical framework in behavioural sciences about how to change behaviour has been applied to stewardship programmes. This working group brings together world experts in antibiotic stewardship with experts in implementation science and behaviour change to address: 1. What behaviour change approaches can be recommended now to optimise hospital stewardship programmes? 2. How can hospital stewardship programmes be designed to optimise implementation across countries? 3. What is the research agenda to optimise efficient implementation of hospital antibiotic stewardship programmes worldwide? Our group recently completed the most comprehensive systematic review to date of 221 intervention studies to improve hospital antibiotic prescribing. The working group has carried out further analysis on the data from this systematic review in order to provide guidance on what behaviour change approaches are effective strategies for optimising stewardship in hospitals. We have completed a further systematic review on the international barriers and facilitators to antibiotic stewardship in 11 hospitals to provide details on the likely challenges that can be encountered when setting up and implementing these programmes. The working group has also completed a structured consensus process to identify and agree research priorities for efforts to optimise behavioural approaches to the implementation of antibiotic stewardship in hospitals worldwide. The research priorities were 1.Conduct robust evaluations of stewardship programmes 2.Establish the role of patients in antibiotic stewardship in hospitals 3.Identify the barriers and facilitators to implementing antibiotic stewardship programmes and good clinical practice 4.Specify the actors and actions required by clinical teams and stewardship programmes 5.Establish the activities in current stewardship programmes 6.Evaluate the role and impact of government and policy context 7.Identify a defined balanced set of outcomes and measures to evaluate the effects of interventions 8.Establish the evidence base for appropriateness 9.Establish how to define and design stewardship programmes 10.Conduct a synthesis of available evidence to support planning for future research and planning for stewardship programmes. We intend to further disseminate these outputs widely including peer-reviewed journal articles, white papers and by incorporating the working group findings into a Massive Online Open Course (MOOC) for health professionals engaged in stewardship efforts.

Antibiotic resistance is a major public health threat. The core of the problem is; 1) overuse/ inappropriate use of antibiotics in both primary and secondary care, driving development of resistance, 2) rapid spread of resistant bacteria, locally through insufficient infection control and public health, and worldwide through travel, and 3) scarce development of new antibiotic agents. Infections caused by multidrug-resistant bacteria are associated with high mortality, prolonged hospital stay, and increased costs. The increased costs arise partially from the need to use more expensive antibiotic therapy, but the longer hospital stay and expenses related to screening, surveillance, containment, and eradication of drug-resistant organisms account for the majority of the excess costs. Antibiotic stewardship programmes in hospitals aim to ensure correct and effective antibiotic treatment of patients with infections and minimise collateral damage from antibiotic use. Furthermore, a robust antibiotic stewardship programme is seen as a key component to reduce healthcare associated infections (HCAI) and improve patient safety. Antibiotic stewardship requires clinicians to change their infection control behaviours. The extent to which current antibiotic stewardship programs have incorporated insights and approaches from behavioural science is uncertain. There is therefore an urgent need to bring together key stakeholders in the design and delivery of stewardship programmes and research experts in improvement and social sciences to develop more impactful antibiotic stewardship programmes.