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Randomized Controlled Trial
. 2024 Oct 18;25(1):691.
doi: 10.1186/s13063-024-08545-4.

Implementation of a tailored multifaceted antibiotic stewardship intervention to improve antibiotic prescribing for urinary tract infections in frail older adults (ImpresU) in four European countries: a process evaluation alongside a pragmatic cluster randomized controlled trial

Esther A R Hartman  1   2   3 , Wim G Groen  4   5 , Silje Rebekka Heltveit-Olsen  6 , Morten Lindbæk  6 , Sigurd Høye  6 , Sara Sofia Lithén  6 , Pär-Daniel Sundvall  7   8 , Sofia Sundvall  8 , Egill Snaebjörnsson Arnljots  7   8 , Ronny Gunnarsson  7   8 , Anna Kowalczyk  9 , Maciej Godycki-Cwirko  9 , Alma C van de Pol  10 , Tamara N Platteel  10 , Annelie A Monnier  4   5 , Theo J M Verheij  10 , Cees M P M Hertogh  4   5
Affiliations
Randomized Controlled Trial

Implementation of a tailored multifaceted antibiotic stewardship intervention to improve antibiotic prescribing for urinary tract infections in frail older adults (ImpresU) in four European countries: a process evaluation alongside a pragmatic cluster randomized controlled trial

Esther A R Hartman et al. Trials. .

Abstract

Background: We previously performed a pragmatic cluster randomized controlled trial (RCT) in general practices and older adult care organizations in Poland, the Netherlands, Norway, and Sweden. We found that a multifaceted antibiotic stewardship intervention (ASI) substantially reduced antibiotic use for suspected urinary tract infections (UTIs) in frail older adults compared with usual care. We aimed to evaluate the implementation process of the ASI to provide recommendations for clinical practice.

Methods: We conducted a process evaluation alongside the cluster RCT. The ASI consisted of a decision-tool and a toolbox, which were implemented using a participatory-action-research (PAR) approach with sessions for education and evaluation. We documented the implementation process of the intervention and administered a questionnaire to health care professionals (HCPs) from participating organizations in the intervention and usual care clusters. We evaluated the multiple components of the intervention and its implementation following a structured framework.

Results: The questionnaire was completed by 254 HCPs from the 38 participating clusters. All components were largely delivered according to plan and evaluated as useful. The decision-tool and toolbox materials were reported to facilitate decision-making on UTIs. Regarding the PAR approach, educational sessions focusing on the distinction between UTIs and asymptomatic bacteriuria were held in all 19 intervention clusters. In 17 out of these 19 clusters, evaluation sessions took place, which were reported to help remind HCPs to implement the ASI. During both sessions, HCPs valued the reflection that took place and the resulting awareness of their behavior. It allowed them to explore implementation barriers and to tailor their local implementation process to overcome these. For example, HCPs organized extra educational sessions or revised local policies to incorporate the use of the decision-tool. Various HCPs took key roles in implementation. Staff changes and the COVID-19 pandemic were important contextual barriers.

Conclusions: We found each component of the multifaceted ASI and its implementation to have added value in the process to improve antibiotic prescribing for suspected UTIs in a heterogeneous older adult care setting. We recommend using a multifaceted, multidisciplinary approach that enables HCPs to reflect on their current practice and accordingly tailor local implementation.

Trial registration: ClinicalTrials.gov NCT03970356. Registered on May 31, 2019.

Keywords: Antibiotic stewardship; Older adults; Process evaluation; Urinary tract infections.

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Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Process evaluation design. The antibiotic stewardship intervention, consisting of a decision-tool and toolbox, was implemented using a participatory-action-research approach with educational and evaluation sessions that allowed for tailoring and flexibility. We evaluated the intervention implementation and usual care, based on a structured framework, using two data sources
Fig. 2
Fig. 2
Evaluation of usefulness of components. Satisfaction of respondents with the fixed components of the antibiotic stewardship intervention and its implementation with a participatory-action-research approach
See this image and copyright information in PMC

References

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