Antimicrobial use: rational or emotional

Cultural drivers of antibiotic prescribing

and how to overcome them

Dr. Michael A. Borg

Mater Dei Hospital

Malta

Behaviour

Rational:

• A process that is based on making decisions or choices that will result in the most optimal level of benefit– Adequate treatment of infectious diseases at the lowest

risk of fostering antibiotic resistance

– Selection of the optimal antimicrobial drug regimen, dose, duration of therapy, and route of administration.

Emotional:

• A behaviour that arises spontaneously rather than through conscious effort.

www.freedictionary.com

Specific

to group Learnt

Specific Inherited and

to individual learnt

Universal Inherited

Influences on behaviour

Culture

Personality

Human nature

Hofstede national dimensions

Cited in >10,000 sociology and psychology publications

The collective programming of the

mind that distinguishes the

members of one group or category

of people from others

Uncertainty Avoidance

Antibiotic prescribing used to reduce uncertainty in the clinician

• Antibiotics given even in dubious clinical presentations – “I started antibiotics... just in case”

• Excessive use of wide spectrum formulations– “We need the widest possible cover”

• Unnecessarily long treatment duration

Ability to handle daily

uncertainties of life and

to avoid stress when in

ambiguous situations

Surgical prophylaxis > 24 hours

20

30

40

50

60

70

80

90

100

30 40 50 60 70 80 90 100 110 120

Pro

po

rtio

n o

f P

AP

>2

4 (

%)

UAI score

Pearson coefficient (r) of correlation:

0.50 (95%CI: 0.16 to 0.74); p = 0.007

Power distance

Inequality exists in all societies but the degree to which inequality is tolerated differs from one culture to another.

All animals are equal but some

animals are more equal than others

(George Orwell: Animal Farm)

• Expert Power

• Perception that one possesses superior skills / knowledge / information.

• Formal hierarchy in decision making

• Subordinates are unlikely to be consulted or to challenge incorrect decisions by superiors

Impact on antibiotic use

• Perceived “threats” to Expert Power often

resisted

– Multi-disciplinary initiatives

– Surveillance and audit

– Prescribing limitations

– Guidelines

• Personal experiences more important than

evidence based science.

• Guidelines:

– Not transferable to patient/clinical situation

– Externally imposed cost containment exercise

– Threatened clinical freedom (i.e. Expert Power)

– No enthusiasm for multi-disciplinary involvement

World map using Hofstede dimensions

Power distance + + + ++ ++ ++ +++ +++ +++ No data

Uncertainty avoidance + ++ +++ + ++ +++ + ++ +++ No data

Masculinity

Masculine are highly target and result oriented.

• Sole focus is to treat the infection

• Ignoring resistance repercussions

• Reinforcement of "treat at all costs" values

Session goals

• After attending this round table the audience

will be able to:

– Know the different strategies published in the

literature about the rational use of antibiotics

– Identify the most relevant aspects in the adequate

use of antimicrobial agents

Cultural comparison

PDI

MASUAI

Argentina

Brazil

Colombia

Uruguay

PDI

MASUAI

Australia

Canada

Great Britain

U.S.A.

Cultural dimensions

10,000 kilometers away

Impact of antibiotic initiatives

in Malta

European comparison

Infrastructure

• Antibiotic CommitteeIf you want to kill any idea in the world,

get a committee working on it.• Especially in high PDI/UAU countries

– Consultative body• Infectious Diseases/Microbiology/Infection Control

• Led by Infection Control – Consultant provided leadership and drive

– “Face” to the programme

• Antibiotic Pharmacist– Critical for progress

– Full time

– “Firewalled” from disgruntled physicians

– “Shared” with Intensive Care

Diagnostic support

• Concentrate on junior doctors– Lower Power (less resistance)

– Greatest Uncertainty (need to pass exams)

– They actually saw the patients!

• Be available for advice– Takes time!!!

• Implement restriction policies– Be ready for intimidation!!

• Produce tools that are appropriate– Antibiotic guidelines

Reduce uncertainty in guidelines

Data gives you power

‘If you cannot

measure it,

you cannot

improve it’

Lord Kelvin, 1824-1907

Antibiotic use surveillance

http://www.escmid.org/research_projects/study_groups/antibiotic_policies/abc_calc/

Carbapenem use in Malta

Year on year increase

Root cause analysis

• Carbapenems prescribed for 101 reasons despite being formulary restricted for sepsis

• Doctors had to fill in a long justification by free text why they were prescribing carbapenems– Reasons often vague and non-specific

• Carbapenems requested for “sepsis” rarely preceded by a blood culture

• Although supposedly “consultant only”, most prescriptions originated from assistants/ senior trainees

• Prolonged duration– De-escalation non-existent

The idiot’s (i.e. Michael’s) guide to

change management

CHANGE

CHANGING OFFERS

AN ADVANTAGE

OR BENEFIT

NOT CHANGING

OFFERS A

DISADVANTAGE

OR LOSS

QUID pro quo

• Request form simplified into a tick box format incorporating all indications in hospital guidelines

– Less time to fill

– Educational tool

• Signature of assistants or senior trainees accepted.

• One 5-day extension accepted without needing to fill a new form.

Quid pro QUO

• Sepsis reinforced as only empiric indication for carbapenems.

• Blood cultures mandatory before treatment

• Not dispensed unless form filled properly

• Request form prepared in self- carbonising triplicate format– copy sent to Infection

Control

– Individually audited by microbiology trainees

• Audit & feedback– Compliance with guidelines

– Blood culture taken

Carbapenem reduction initiative:

Mater Dei Hospital

• Simplified form

• Assistant/senior trainee

signature accepted

– Consultants happy

– Junior doctors happy

• Red tape improved

• Blood culture mandatory• Assistants started to put

pressure on consultants to avoid unnecessary cultures

• Non-compliance queried• Phone calls in real time to

doctors

• League tables of non-compliance published by consultant firm

• Sent to CEO

• Unpopular with clinicians

• CRE outbreak “exploited”

Carbapenem use 2009 - 2012DDD per

100BD

Conclusion

• Solid hypothesis that antibiotic prescribing seems to be influenced by cultural backgrounds

– Uncertainty avoidance & power distance

• Overcoming the challenge is not easy

– Nevertheless it is possible to address sub-optimal antibiotic use, even in unfavourable cultural environments

• It is critical to understand your local situation and your local culture

– Devise customised interventions that have the best chance to work.

Thank you