Evaluating the effectiveness of carbapenem and piperacillin-tazobactam prescribing guidelines and implementation strategies on multi-drug resistant gram-negative bacteria within NHS Scotland

Student thesis: Doctoral Thesis

Abstract

Background: Antimicrobial resistance is one of the most challenging aspects of healthcare worldwide. In 2013 the Scottish Antimicrobial Prescribing Group (SAPG) produced guidance to promote better use of carbapenems and piperacillin-tazobactam as a measure to reduce emergence of Multi-Drug Resistant Gram Negative Bacteria (MDRGNB). The effectiveness of implementation of this national guidance and its impact on the utilisation of these agents in local clinical practice was unknown.Objectives: To evaluate how SAPG guidance against MDRGNB had been adopted and implemented across NHS Scotland health boards, assess how this translated into clinical practice, and investigate clinicians' views and behaviours about prescribing carbapenems and alternative agents.Methods: The current research was divided into three parts; online survey, national point prevalence surveillance, and semi-structured interviews. Part one: Local implementation of SAPG MDRGNB guidance was assessed from local AMT committee's responses using an online survey. Part two: A bespoke national point prevalence survey was used to evaluate prescribing of meropenem and piperacillin-tazobactam in clinical practice. Part three: Clinicians' experience of using carbapenems and alternatives was examined through semi-structured interviews within four health boards.Results: Part one: all 15 health boards responded to the survey. There were greater local restrictions for carbapenems than for piperacillin-tazobactam. Meropenem was the most common used carbapenem. Laboratory result suppression was inconsistent between health boards and carbapenem-sparing antimicrobials were not widely available. Part two: 13 health boards were included and a total of 12,478 inpatients in 38 hospitals were surveyed. Adherence to local guidelines was good for meropenem but lower for piperacillin-tazobactam. Indication for use was well documented but review/stop dates were poorly documented for both antimicrobials.Part three: 28 interviews were conducted. Decisions to prescribe a carbapenem were influenced by local guidelines and specialist team's advice. Many clinicians lacked confidence to de-escalate treatment. Use of both antimicrobials decreased during the course of the programme.Conclusions: A multifaceted quality improvement programme was used to gather intelligence, promote behaviour change, and focus interventions on the use of carbapenems and piperacillin-tazobactam. Use of these antimicrobials decreased during the programme, a trend not seen elsewhere in Europe. The programme identified variation in practice and guidance adaptation between health boards, and different approaches had been adopted to encounter MDRGNB. The importance of local guidelines and support of specialised teams were highly influential and much appreciated between participants. The programme could be generalised to other antimicrobials in future.
Date of Award1 Jun 2017
LanguageEnglish
Awarding Institution
  • University Of Strathclyde
SupervisorIbrahim Khadra (Supervisor) & Marion Bennie (Supervisor)

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