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Dear colleague,

ESGAP, in close cooperation with SWAB (the Dutch Working Group on Antimicrobial Policies) would like to make an inventory of the organizational

characteristics and activities of Antimicrobial Stewardship Programs (ASPs) in Europe.

With funding from the Federation of Dutch Scientific Societies, an independent institute (IQ healthcare, Radboud University Medical Centre) has developed this questionnaire on Antimicrobial Stewardship in hospitals. The questionnaire was developed following a systematic literature review and includes among others the

structure and process indicators for ASPs as developed by TATFAR, the Transatlantic Taskforce on Antimicrobial Resistance.

We would like to ask you to fill in this questionnaire before September 1st by clicking on the link below. It will take up to 30 minutes to do so.

Thank you for your cooperation!

Yours sincerely,

Marlot Kallen, PhD student, Infectious Diseases, Academic Medical Center, Amsterdam, the Netherlands

Jaap ten Oever, Infectious Diseases specialist, Radboud University Medical Center, Nijmegen, the Netherlands

Jeroen Schouten, internist-intensivist, CWZ, Nijmegen, the Netherlands and Executive Committee member at ESGAP

Marlies Hulscher, professor Quality of care for infectious and inflammatory diseases, Radboud University Medical Center, Nijmegen, the Netherlands

This questionnaire aims at making an inventory of:

· The organisation of Antimicrobial Stewardship Programs in Europe;

· Hospital resources for Antimicrobial Stewardship in Europe;

Section A: 1. Hospital information

A1. In what country are you employed?

A2. In which hospital are you employed?

A3. Is your hospital part of a collaborative hospital group?

Yes

A4. Please state the number of beds in your hospital:

A5. What is the hospital type?

No

Academic hospital

Non-academic teaching hospital

General non-teaching hospital

A6. Does your hospital provide the following hospital residency programs: (multiple answers possible)

Internal medicine

Infectious diseases

(Clinical) Microbiology

Clinical pharmacy

None of these

A7. Does your hospital have an Infectious Diseases (ID) specialist?Yes

A8. Does your hospital have a Clinical Microbiologist?

No

Yes

No, a microbiologist is available but without clinical tasks

No, but can be consulted from an external location

No

A9. Does your hospital have a Clinical Pharmacist, with specific interest in the field of antimicrobials?

Yes

No

Section B: 2a. Organisation of an Antimicrobial Stewardship Program

B1. Does your hospital have a formal Antimicrobial Stewardship Program (ASP) to ensure appropriate antimicrobial use?

Antimicrobial Stewardship Program (ASP) = a coordinated hospital program that promotes the appropriate use of antimicrobials by professionalsto reduce the development of antimicrobial resistance

Yes

No

B2. Does your hospital produce an annual report focusing on Antimicrobial Stewardship?

Annual report = a summary of antimicrobial use and/or practices initiatives to improve the appropriateness of antimicrobial use

Yes

B3. Does your facility have a formal organisational structure for Antimicrobial Stewardship embedded in (e.g. a multidisciplinary committee focused on appropriate antimicrobial use, a pharmacy committee, a patient safety committee)?

No

Yes

No

B4. Is an Antimicrobial Stewardship team available at your hospital?Antimicrobial Stewardship team (A-team) = a multi-disciplinary team, larger than one staff member, that monitors antibiotic use and supports

clinical decisions to ensure appropriate antibiotic use

Yes

B5. Are preparations being made to establish one?

No

Yes

B6. Does this A-team function in a coordinating role at several locations within a hospital group?

No

Yes

No

B7. In what year was the A-team established?

B8. Which type of professionals are part of the A-team? (multiple answers possible)Number of persons:

Clinical Microbiologist

Clinical Pharmacist

Infectious Diseases specialist

Internist (non-ID specialist)

Paediatrician

Quality of care officer

Infection prevention specialist

Nurse

Epidemiologist

Other

B9. Specify other type of care professional:

B10. How much time (in hours) does this profession within the A-team dedicate to Antimicrobial Stewardship related activities? N.B. count up the time of all professionals from the same profession If you can not assess, please enter -1Time spent (hours/week):


B11. How much salary support (in full-time equivalents (FTEs)) is provided for this profession by your hospital? N.B. count up the salaries of all professionals from the same profession. If you can not assess, please enter -0.1Salary support (fte):


B12. How much time (in hours) does this profession within the A-team dedicate to Antimicrobial Stewardship related activities? N.B. count up the time of all professionals from the same profession If youcan not assess, please enter -1Time spent (hours/week):

Clinical Pharmacist

B13. How much salary support (in full-time equivalents (FTEs)) is provided for this profession by your hospital? N.B. count up the salaries of all professionals from the same profession. If you can not assess, please enter -0.1

Salary support (fte):Clinical Pharmacist










Paediatrician


Paediatrician

B20. How much time (in hours) does this profession within the A-team dedicate to Antimicrobial Stewardship related activities? N.B. count up the time of all professionals from the same profession If you can not assess, please enter -1

Time spent (hours/week):Quality of care officer








Nurse


Nurse


Epidemiologist

B27. How much salary support (in full-time equivalents (FTEs)) is provided for this profession by your hospital? N.B. count up the salaries of all professionals from the same profession. If you can not assess, please enter -0.1

Salary support (fte):Epidemiologist


Other type of care professional



Section C: 2b. Organisation of an Antimicrobial Stewardship Program

C1. How often does the A-team hold policy meetings? (meetings in which coordinating issues referring to local Antimicrobial Stewardship activities are discussed)

Daily

Once a week

Once every 2 weeks

Once a month

Once every 2 months

Four times a year

Once a year

C2. Specify how often the A-team holds policy meetings:

Other

C3. How many times per year does the A-team hold coordinating meetings with the Hospital Infection Committee?

Hospital Infection Committee = a local multi-disciplinary committee to prevent and control nosocomial infections

C4. How many times per year does the A-team hold coordinating meetings with the Hospital Antibiotic Committee / Hospital Formulary Committee?

Hospital Antibiotic Committee / Hospital Formulary Committee = a local multi-disciplinary committee responsible for compiling, maintaining andupdating its antibiotic formulary

C5. How many times per year does the A-team hold coordinating meetings with other hospitals?

C6. Has authority been granted from the Hospital Board of Directors to the A-team?

Yes

C7. Does the Hospital Board of Directors provide a budget for an Antimicrobial Stewardship program (not including FTEs for members of the antibiotic team) ?

No

Yes

C8. Does your hospital have a named senior executive officer with accountability for antimicrobial leadership?

No

Yes

C9. Has a professional been identified as a leader for Antimicrobial Stewardship activities?

No

No leader




Clinical Pharmacist

Paediatrician



Nurse

Epidemiologist


C10. Specify other type of care professional:

C11. Has this professional received specialised training in Antimicrobial Stewardship?

Yes

C12. Are stewardship activities included in the professionals job description and/or annual review?

No

Yes

No

C13. Does your hospital have antibiotic guardians (e.g. ambassadors) who propagate appropriate use of antimicrobials on their ward?

On all wards

On nearly all wards

On half of all wards

On a number of wards

Not on any ward

Section D: 3. Hospital resources for Antimicrobial Stewardship

Medical recordGuidelines and Antimicrobial Formulary IT support

D1. What type of medical record does your hospital use? (multiple answers possible)

No medical record

On paper

Electronic

D2. What type of Electronic Medical Record software does your hospital use?

D3. What type of medical data can be consulted in this system? (multiple answers possible)

Clinical data

Medication data

Laboratory data (i.e. clinical chemistry)

Microbiology data

Radiology data

D4. Does your hospital have a local Antimicrobial Formulary?

None of these

Antimicrobial formulary = a list of antimicrobials that the hospital pharmacy stocks, along with information about each specific drug (this may bepart of a general drug Formulary in your hospital). These are NOT local antibiotic guidelines

Yes

No

D5. Does this local Antimicrobial Formulary contain a list of restricted antimicrobial agents?

Restricted antimicrobial agents = antimicrobials needing prior authorisation by an ID specialist, Clinical Microbiologist or Clinical Pharmacist

Yes

No

D6. Where can this local Antimicrobial Formulary be found? (multiple answers possible)

Electronically via internet

Electronically via intranet

Electronically through a mobile application

Printed in a pocket guide

Printed version in the physicians' room

D7. Specify where the local Antimicrobial Formulary can be found:

Other

D8. Does your hospital have local guidelines for common infectious diseases?

Local guidelines = facility-specific evidence based treatment recommendations that assist professionals in their decision making on diagnostics andtreatment

Yes

No

D9. Are these local guidelines based on local antimicrobial susceptibility?

Yes

No

D10. How can these local guidelines be consulted? (multiple answers possible)

Electronically via internet

Electronically via intranet

Electronically through a mobile application

Printed in a pocket guide

Printed version in the physicians' room

D11. Specify how the local guidelines can be consulted:

Other

D12. Has your hospital implemented standardized criteria for (multiple answers possible):

Switch from intravenous to oral antimicrobial therapy

Streamlining / de-escalation of empirical antimicrobial therapy

Dose optimisation (TDM)

Discontinuation of antimicrobial therapy

Surgical prophylaxis

None of these

D13. Does your hospital have a written policy that requires prescribers to document an indication in the medical record or during order entry for all antimicrobial prescriptions?

Yes

No

D14. Does your hospital have the IT capability to support the needs of Antimicrobial Stewardship activities?

IT formation has officially been allocated to the A-team (in FTE’s)

IT support can be applied for if needed

No IT support available

Other

D15. Specify IT capability:

D16. Does your hospital use IT support for the following Antimicrobial Stewardship related activities (multiple answers possible):

Selection of specified patient categories

Data reporting

Point Prevalence Survey (PPS)

Decision support (i.e. using clinical rules)

Other

D17. Specify other Stewardship related activities for which your hospital uses IT support:

Section E: 4. Stewardship activitiesMonitoring the quantity of antimicrobial useMonitoring the appropriateness of antimicrobial use Improving the appropriateness of antimicrobial useExtra questionsThank you for filling out the Antimicrobial Stewardship questionnaire!

E1. Does your hospital monitor the quantity of antimicrobial use?Monitoring = the activity of continuous measurement and reporting on relevant aspects of clinical care (such as IV oral switch in eligible patient)

to ensure that stewardship goals are met

Yes

No

E2. How many times per year does the A-team receive feedback on the quantitative use of antimicrobials?

E3. What statistical measure does your hospital apply for quantitative antimicrobial use?

Defined Daily Dose (DDD) [by grams]

Days of Therapy (DOT) [by counts]

E4. Specify other statistical measure:

Other

E5. Does the microbiology department in your hospital produce cumulative antimicrobial susceptibility reports?

Yes

No

E6. How many times per year does the A-team receive feedback on these cumulative antimicrobial susceptibility reports?

E7. How does your hospital monitor the use of restricted antimicrobial agents? (multiple answers possible) Please note: patient categories can relate to syndromes, departments or agents

Monitoring = the activity of continuous measurement and reporting on relevant aspects of clinical care (such as IV oral switch in eligible patient)to ensure that stewardship goals are

met Restricted antimicrobial agents = antimicrobials needing prior authorisation by an ID specialist, Clinical Microbiologist or Clinical

Pharmacist

Pre-authorisation = prescribing restricted agents only after

authorisation Post-authorisation = continuation of a specific agent requires authorisation after the

first administration

Formulary restriction = restricted agents are not available

Antibiotic Order forms = documenting clinical indication when prescribing restricted agents

Post-prescription review = monitoring and advice 48-72 hrs after prescribing restricted agents

No monitoring of restricted agents

Pre-authorisation of restricted agents

Post-authorisation of restricted agents

Formulary restriction

Antibiotic order forms

Computerised alert when prescribing restricted agents

Check whether diagnostic tests were performed when prescribing restricted agents

Mandatory bedside consultation when prescribing restricted agents

Feedback by telephone after prescription of restricted agents

Post prescription review

Stop orders for restricted agents

E8. Specify other activities:

Other

E9. Please specify post-prescription reviewContinuous monitoring and advice of all patients who receive restricted agents

Occasional monitoring and advice of all patients who receive restricted agents (audit)

Continuous monitoring and advice of specific patient categories who receive restricted agents

Occasional monitoring and advice of specific patient categories who receive restricted agents (audit)

E10. Please specify which specific patient categories:

E11. Does your hospital perform bedside ID consultations?

Yes

No

E12. For which type of infection has your hospital agreed to perform bedside ID consultation? (multiple answers possible)

Staphylococcus aureus bacteraemia

Infective endocarditis

Infection of a prosthetic joint

Infection of a vascular/valvular prosthesis

Invasive fungal infection

E13. Specify other type of infection:

Other

E14. For which type of infection does your hospital monitor performance of bedside consultations? (multiple answers possible)

Monitoring = the activity of continuous measurement and reporting on relevant aspects of clinical care (such as IV oral switch in eligible patient)to ensure that stewardship goals are met

No monitoring

Staphylococcus aureus bacteraemia

Infective endocarditis

Infection of a prosthetic joint

Infection of a vascular/valvular prosthesis

Invasive fungal infection

E15. Specify other type of infection:

Other

E16. Does your hospital advise on adherence to guidelines for empirical antimicrobial use (e.g. in cases of pneumonia or urinary tract infections)? (multiple answers possible)

Guidelines = evidence based treatment recommendations that assists professionals in their decision making on diagnostics and treatment forspecific disease

No advice

Yes, advice is provided when an ID physician or clinical microbiologist is consulted by the clinician

Yes, advice is provided based on results from monitoring or audits (proactive)

E17. How does your hospital advise on adherence to guidelines for empirical use? (multiple answers possible)

Alert or note in the Electronic Patient Record

By telephone

Face-to-face on the ward (i.e. during structural patient consultation or multidisciplinary meetings)

E18. Specify other:

Other

E19. How does your hospital monitor adherence to guidelines for empirical use of antimicrobials? (multiple answers possible)

Point Prevalence Survey (PPS) = A cross-section measurement of the quality of antimicrobial use

Audit = a longitudinal measurement on the quality of antimicrobial use

Continuous monitoring (4-7 days a week)

Occasional monitoring (1-3 days a week )

Incidental monitoring and advice (PPS or audit)

E20. For which patient categories does your hospital monitor adherence to guidelines for empirical use?Please note: patient categories can relate to syndromes, departments or agents

Monitoring of all patients

E21. Specify patient category:

Monitoring of specific patient categories

E22. On which specific ‘day of therapy’ does your hospital monitor adherence to guidelines for empirical use? (multiple answers possible)

No specific day

Monitoring on day 1 (start therapy)

Monitoring on day 2-3


E23. Specify other:

Other

E24. Does your hospital advise on timely switch from intravenous to oral antimicrobial therapy? (multiple answers possible)

No advice

Yes, advice is given when an ID physician or clinical microbiologist is consulted by the clinician

Yes, advice is given based on results from monitoring or audits (proactive)

E25. How does your hospital advise on timely switch from intravenous to oral antimicrobial therapy? (multiple answers possible)


By telephone


E26. Specify other:

Other

E27. How does your hospital monitor timely switch from intravenous to oral antimicrobial therapy? (multiple answers possible)




Occasional monitoring (1-3 days a week )


E28. For which patient categories does your hospital monitor timely switch from intravenous to oral antimicrobial therapy? Please note: patient categories can relate to syndromes, departments or agents




E30. On which specific ‘day of therapy’ does your hospital monitor timely switch from intravenous to oral antimicrobial therapy? (multiple answers possible)

No specific day



Other

E31. Specify other:

E32. Does your hospital advise on streamlining / de-escalation of antimicrobial therapy? (multiple answers possible)

No advice



E33. How does your hospital advise on streamlining / de-escalation of antimicrobial therapy? (multiple answers possible)


By telephone


E34. Specify other:

Other

E35. How does your hospital monitor streamlining / de-escalation of antimicrobial therapy? (multiple answers possible)




Occasional monitoring (1-3 days a week)


E36. For which patient categories does your hospital monitor streamlining/ de-escalation of antimicrobial therapy?

Please note: patient categories can relate to syndromes, departments or agents




E38. On which specific ‘day of therapy’ does your hospital monitor streamlining / de-escalation of antimicrobial therapy? (multiple answers possible)

No specific day



E39. Specify other:

Other

E40. Does your hospital advise on discontinuation of antimicrobial therapy? (multiple answers possible)

No advice



E41. How does your hospital advise on discontinuation of antimicrobial therapy? (multiple answers possible)


By telephone


E42. Specify other:

Other

E43. How does your hospital monitor discontinuation of antimicrobial therapy? (multiple answers possible)






E44. For which patient categories does your hospital monitor discontinuation of antimicrobial therapy?



Monitoring of specific patient categories:


E46. When does your hospital monitor discontinuation of antimicrobial therapy? (multiple answers possible)

Prospectively: monitoring during antimicrobial therapy whether discontinuation is an option

Retrospectively: monitoring whether antimicrobial therapy was discontinued at the right moment

E47. Specify other:

Other

E48. Does your hospital advise on therapeutic drug monitoring (TDM)? (multiple answers possible)

Therapeutic drug monitoring (TDM) = the measurement of medication concentrations in blood

No advice



E49. How does your hospital advise on TDM? (multiple answers possible)Alert or note in the Electronic Patient Record

By telephone


E50. Specify other:

Other

E51. How does your hospital monitor the performance of TDM? (multiple answers possible)






E52. Which antimicrobials does your hospital monitor regarding TDM? (multiple answers possible)

Gentamicin

Tobramycin

Amikacin

Vancomycin

Voriconazole

Posaconazole

E53. Specify other:

Other

E54. Does your hospital advise on the prescription of surgical prophylaxes? (multiple answers possible)

Surgical prophylaxes = the use of antimicrobials to prevent infections at the surgical site

No advice



E55. How does your hospital advise on the prescription of surgical prophylaxes? (multiple answers possible)


By telephone


E56. Specify other:

Other

E57. How does your hospital monitor the prescription of surgical prophylaxes? (multiple answers possible)






E58. For which patient categories does your hospital monitor the prescription of surgical prophylaxes?

Please note: patient categories can relate to syndromes, departments, agents or length of therapy

Monitoring of all surgical patients

Monitoring of surgical patients with prolonged surgical prophylaxes (> 24 hrs)



E60. When does your hospital monitor the prescription of surgical prophylaxes? (multiple answers possible)

Prospectively: monitoring during prophylactic therapy whether discontinuation is an option

Retrospectively: monitoring whether antimicrobial prophylaxes were discontinued at the right moment

E61. Specify other:

Other

E62. Does your hospital advise on the correct use of diagnostics (e.g. drawing blood cultures)? (multiple answers possible)

No advice



E63. How does your hospital advise on the correct use of diagnostics? (multiple answers possible)


By telephone


E64. Specify other:

Other

E65. How does your hospital monitor correct use of diagnostics? (multiple answers possible)






E66. For which patient categories does your hospital monitor correct use of diagnostics?





E68. Does your hospital check the appropriateness of antimicrobial use with Point Prevalence Surveys (PPS)?


Yes

E69. How often is a PPS performed in your hospital?

No

Structurally 2x per year

Structurally 1x per year

Structurally 1x every 2 years

Incidentally

E70. Specify other:

Other

E71. Which standardized system does your hospital use when performing a PPS? (multiple answers possible)

ECDC

WHO

National PPS system

E72. Specify other system:

Other

E73. Is a daily care bundle for antibiotic use implemented in your hospital?

Care bundle = A bundle is a small and structured set of evidence-based practices — generally three to five — that, when performed collectivelyand reliably, have been proven to improve patient outcomes

No

On all wards

On specific wards, including (fill in what kind of wards in the next question):

E74. Specify wards:

E75. Does your hospital use a daily checklist for antibiotic use?Checklist = A list of practices relating to antibiotic use to be performed and checked daily

No

On all wards

On specific wards, including (fill in what kind of wards in the next question):

E76. Specify wards:

E77. Does your hospital provide education to residents on Antimicrobial Stewardship?

Yes

E78. Is this type of education:

No

Voluntary

E79. How often does this take place?

Mandatory

Once a week

Once a month

Once every 2 months

4x per year

2x per year

Once every year

On demand

E80. Specify:

Other

E81. Which subjects are discussed in the training of residents? (multiple answers possible)

Antimicrobial resistance

Specific syndromes (e.g. S. aureus, CAP, endocarditis)

Use and supervision of restricted medication (e.g. pre-authorisation)

Switch from intravenous to oral

Streamlining / de-escalation of antimicrobial therapy

Therapeutic drug monitoring (TDM)

Point prevalence survey and audit

E82. Specify other subjects:

Other

E83. Does your hospital provide education to medical specialists on Antimicrobial Stewardship?

Yes

E84. Is this type of education:

No

Voluntary

E85. How often does this take place?

Compulsory

Daily

Once a week

Once a month

Once every 2 months

4x per year

2x per year

Once every year

On demand

E86. Specify:

Other

E87. Which subjects are discussed in the training of medical specialists? (multiple answers possible)

Streamlining / de-escalation = adaptation and if possible narrowing of antimicrobial therapy based on culture

results Therapeutic drug monitoring (TDM) = the measurement of medication concentrations

in blood Point Prevalence Survey (PPS) = A cross-section measurement of the quality of

antimicrobial use


Antimicrobial resistance

Specific syndromes (e.g. S. aureus, CAP, endocarditis)

Use and supervision of restricted medication (e.g. pre-authorisation)

Switch from intravenous to oral

Streamlining / de-escalation of antimicrobial therapy

Therapeutic drug monitoring (TDM)

Point prevalence survey and audit

E88. Specify other subject:

Other

E89. Does your hospital provide feedback of PPS or audit results to frontline health care workers?

Frontline = physicians who directly provide “services” in daily practice (e.g. internist, microbiologists)

Yes

No

E90. Is your hospital engaged in Stewardship related activities that have not been mentioned above?

E91. In your opinion, what are the most successful aspects of the Stewardship program in your hospital?

E92. Please note any remarks you may have in the box below:

Thank you for filling out the questionnaire

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