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Morley VJ, Firgens EPC, Vanderbilt RR, Zhou Y, Zook M, Read AF, MacGeorge EL. Factors associated with antibiotic prescribing for acute bronchitis at a university health center. BMC Infect Dis 2020; 20:177. [PMID: 32102652 PMCID: PMC7045376 DOI: 10.1186/s12879-020-4825-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 01/24/2020] [Indexed: 11/10/2022] Open
Abstract
Background Antibiotics are not indicated for treating acute bronchitis cases, yet up to 70% of adult acute bronchitis medical visits in the USA result in an antibiotic prescription. Reducing unnecessary antibiotic prescribing for acute bronchitis is a key antibiotic stewardship goal set forth by the Centers for Disease Control and Prevention. Understanding what factors influence prescribing for bronchitis cases can inform antimicrobial stewardship initiatives. The goal of this study was to identify factors associated with antibiotic prescribing at a high-volume student health center at a large US university. The Pennsylvania State University Health Services offers on-campus medical care to a population of over 40,000 students and receives over 50,000 visits every year. Methods We conducted a retrospective chart review of acute bronchitis visits for the 2015–2016 academic year and used a multivariate logistic regression analysis to identify variables associated with antibiotic prescribing. Results Findings during lung exams increased the likelihood of an antibiotic prescription (rales OR 13.95, 95% CI 3.31–80.73; rhonchi OR 5.50, 95% CI 3.08–10.00; percussion abnormality OR 13.02, 95% CI 4.00–50.09). Individual clinicians had dramatically different rates of prescribing (OR range 0.03–12.3). Male patients were more likely than female patients to be prescribed antibiotics (OR 1.68, 95% CI 1.17–2.41). Patients who reported longer duration since the onset of symptoms were slightly more likely to receive prescriptions (OR 1.04 per day, 95% CI 1.03–1.06), as were patients who reported worsening symptoms (OR 1.78, 95% CI 1.03–3.10). Visits with diagnoses or symptoms associated with viral infections or allergies were less likely to result in prescriptions (upper respiratory tract infection (URI) diagnosis OR 0.33, 95% CI 0.18–0.58; sneezing OR 0.39, 95% CI 0.17–0.86; vomiting OR 0.31, 95% CI 0.10–0.83). An exam finding of anterior cervical lymphadenopathy was associated with antibiotic prescribing (tender OR 3.85, 95% CI 1.70–8.83; general OR 2.63, 95% CI 1.25–5.54). Conclusions Suspicious findings during lung examinations (rales, rhonchi, percussion abnormality) and individual healthcare providers were important factors influencing antibiotic prescribing rates for acute bronchitis visits. Patient gender, worsening symptoms, duration of illness, symptoms associated with viral infections or allergies, and anterior cervical lymphadenopathy also influenced prescribing rates.
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Affiliation(s)
- Valerie J Morley
- Center for Infectious Disease Dynamics, Department of Biology, The Pennsylvania State University, University Park, State College, PA, USA
| | - Emily P C Firgens
- Department of Communication Arts & Sciences, The Pennsylvania State University, University Park, State College, PA, USA
| | - Rachel R Vanderbilt
- Department of Communication Arts & Sciences, The Pennsylvania State University, University Park, State College, PA, USA
| | - Yanmengqian Zhou
- Department of Communication Arts & Sciences, The Pennsylvania State University, University Park, State College, PA, USA
| | - Michelle Zook
- University Health Services, The Pennsylvania State University, University Park, State College, PA, USA
| | - Andrew F Read
- Center for Infectious Disease Dynamics, Department of Biology, The Pennsylvania State University, University Park, State College, PA, USA.,Huck Institutes for the Life Sciences, The Pennsylvania State University, University Park, State College, PA, USA.,Department of Entomology, The Pennsylvania State University, University Park, State College, PA, USA
| | - Erina L MacGeorge
- Department of Communication Arts & Sciences, The Pennsylvania State University, University Park, State College, PA, USA.
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102
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Kinoshita N, Komura M, Tsuzuki S, Shoji K, Miyairi I. The effect of preauthorization and prospective audit and feedback system on oral antimicrobial prescription for outpatients at a children's hospital in Japan. J Infect Chemother 2020; 26:582-587. [PMID: 32088130 DOI: 10.1016/j.jiac.2020.01.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Revised: 01/25/2020] [Accepted: 01/27/2020] [Indexed: 11/15/2022]
Abstract
Antimicrobial stewardship programs (ASP) for oral antibiotics is still uncommon, despite the fact that oral antibiotics prescription accounts for 90% of total antibiotic consumption in developed countries. We introduced preauthorization and prospective audit and feedback (PAF) system on broad-spectrum oral antimicrobials as a part of ASP intervention from October 2015 in a tertiary children's hospital in Japan. Antimicrobial consumption and cost of targeted oral antimicrobials decreased from 11.1 days of therapy (DOT) per 1000 outpatient visits and 860,040 yen ($ 7167: 1 $ = 120 yen) to 1.9 DOT per 1000 outpatient visits and 142,200 yen ($ 1185) annually, respectively (p < 0.001). Interrupted time-series analysis showed that prescriptions for targeted antimicrobials decreased rapidly after initiation of preauthorization (p < 0.001). Prescriptions for non-targeted oral antimicrobial increased temporarily (p < 0.001), but a decreasing trend was found after the initiation (p < 0.001). In pre-intervention period, the main indications for using targeted antimicrobials were upper and lower respiratory infection, urinary tract infections, prophylaxis for medical procedures and otitis media, but only 21.4% of them were appropriate prescription. The appropriate prescription rate of post -intervention period increased to 58.5%. During the study period, the susceptibility pattern of major bacteria to these antimicrobials did not change. In conclusion, introduction of the preauthorization and PAF for selected oral antimicrobials decreased the antimicrobial use of both targeted and non-targeted antimicrobials. This intervention may be an effective method of ASP for other children's hospitals.
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Affiliation(s)
- Noriko Kinoshita
- Division of Infectious Diseases, Department of Medical Subspecialties, National Center for Child Health and Development, Tokyo, Japan; Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan.
| | - Makoto Komura
- Department of Pharmaceuticals, National Center for Child Health and Development, Tokyo, Japan.
| | - Shinya Tsuzuki
- AMR Clinical Reference Center, Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan; Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.
| | - Kensuke Shoji
- Division of Infectious Diseases, Department of Medical Subspecialties, National Center for Child Health and Development, Tokyo, Japan.
| | - Isao Miyairi
- Division of Infectious Diseases, Department of Medical Subspecialties, National Center for Child Health and Development, Tokyo, Japan.
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103
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Pulia MS, Keller SC, Crnich CJ, Jump RLP, Yoshikawa TT. Antibiotic Stewardship for Older Adults in Ambulatory Care Settings: Addressing an Unmet Challenge. J Am Geriatr Soc 2020; 68:244-249. [PMID: 31750937 PMCID: PMC7228477 DOI: 10.1111/jgs.16256] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 10/14/2019] [Accepted: 10/17/2019] [Indexed: 01/21/2023]
Abstract
Inappropriate antibiotic use is common in older adults (aged >65 y), and they are particularly vulnerable to serious antibiotic-associated adverse effects such as cardiac arrhythmias, delirium, aortic dissection, drug-drug interactions, and Clostridioides difficile. Antibiotic prescribing improvement efforts in older adults have been primarily focused on inpatient and long-term care settings. However, the ambulatory care setting is where the vast majority of antibiotic prescribing to older adults occurs. To help improve the clinical care of older adults, we review drivers of antibiotic prescribing in this population, explore systems aspects of ambulatory care that can create barriers to optimal antibiotic use, discuss existing stewardship interventions, and provide guidance on priority areas for future inquiry. J Am Geriatr Soc 68:244-249, 2020.
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Affiliation(s)
- Michael S Pulia
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin Madison School of Medicine and Public Health, Madison, Wisconsin
| | - Sara C Keller
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Christopher J Crnich
- Department of Medicine, University of Wisconsin Madison School of Medicine and Public Health, Madison, Wisconsin
- William S. Middleton Veterans Affairs Medical Center, Madison, Wisconsin
| | - Robin L P Jump
- Geriatric Research, Education and Clinical Center, VA Northeast Ohio Healthcare System, Cleveland, Ohio
- Specialty Care Center of Innovation, VA Northeast Ohio Healthcare System, Cleveland, Ohio
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Thomas T Yoshikawa
- Department of Veterans Affairs Greater Los Angeles Healthcare System, Geriatric and Extended Care Service and Geriatric Research, Education and Clinical Center, Los Angeles, California
- Department of Medicine, Department of Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California
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104
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Anyanwu PE, Borek AJ, Tonkin-Crine S, Beech E, Costelloe C. Conceptualising the Integration of Strategies by Clinical Commissioning Groups in England towards the Antibiotic Prescribing Targets for the Quality Premium Financial Incentive Scheme: A Short Report. Antibiotics (Basel) 2020; 9:antibiotics9020044. [PMID: 31979209 PMCID: PMC7167865 DOI: 10.3390/antibiotics9020044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 01/06/2020] [Accepted: 01/21/2020] [Indexed: 12/02/2022] Open
Abstract
Background: In order to tackle the public health threat of antimicrobial resistance, improvement in antibiotic prescribing in primary care was included as one of the priorities of the Quality Premium (QP) financial incentive scheme for Clinical Commissioning Groups (CCGs) in England. This paper briefly reports the outcome of a workshop exploring the experiences of antimicrobial stewardship (AMS) leads within CCGs in selecting and adopting strategies to help achieve the QP antibiotic targets. Methods: We conducted a thematic analysis of the notes on discussions and observations from the workshop to identify key themes. Results: Practice visits, needs assessment, peer feedback and audits were identified as strategies integrated in increasing engagement with practices towards the QP antibiotic targets. The conceptual model developed by AMS leads demonstrated possible pathways for the impact of the QP on antibiotic prescribing. Participants raised a concern that the constant targeting of high prescribing practices for AMS interventions might lead to disengagement by these practices. Most of the participants suggested that the effect of the QP might be less about the financial incentive and more about having national targets and guidelines that promote antibiotic prudency. Conclusions: Our results suggest that national targets, rather than financial incentives are key for engaging stakeholders in quality improvement in antibiotic prescribing.
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Affiliation(s)
- Philip Emeka Anyanwu
- Global Digital Health Unit, Department of Primary Care and Public Health, Imperial College London, London W6 8RP, UK;
- Correspondence:
| | - Aleksandra J. Borek
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford OX2 6GG, UK; (A.J.B.); (S.T.-C.)
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford OX2 6GG, UK; (A.J.B.); (S.T.-C.)
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford OX2 6GG, UK
| | - Elizabeth Beech
- NHS Bath and North East Somerset Clinical Commissioning Group, NHS Improvements London, London BA2 5RP, UK;
| | - Céire Costelloe
- Global Digital Health Unit, Department of Primary Care and Public Health, Imperial College London, London W6 8RP, UK;
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105
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Yadav K, Stahmer A, Mistry RD, May L. An Implementation Science Approach to Antibiotic Stewardship in Emergency Departments and Urgent Care Centers. Acad Emerg Med 2020; 27:31-42. [PMID: 31625653 DOI: 10.1111/acem.13873] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 10/08/2019] [Accepted: 10/13/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Antibiotic stewardship efforts have expanded focus from inpatient to include outpatient settings. However, stewardship is urgently needed in acute care ambulatory settings: emergency departments (EDs) and urgent care centers (UCCs). Implementation of antibiotic stewardship in acute ambulatory care settings has been limited. Two major barriers to effective implementation exist: 1) lack of adaptation of successful outpatient stewardship interventions to the acute care ambulatory setting and 2) absence of rigorous measurement of implementation processes in EDs and UCCs in a manner that informs future scale and spread. OBJECTIVES Our objective was to apply an implementation science approach to address antibiotic overuse and inappropriate use in EDs and UCCs. METHODS This study was a redesign of an evidence-based outpatient antibiotic stewardship intervention at participating EDs and UCCs using an innovative implementation science framework (dynamic adaptation process), adaptable for local clinical workflow and local champion provision. We evaluated multiple implementation outcome metrics throughout a cluster-randomized comparative effectiveness clinical trial of two approaches to the adapted antibiotic stewardship interventions. RESULTS Our preimplementation phase included 21 in-depth interviews and online provider surveys (52% response rate). For the postimplementation survey, we had a 39% response rate. We identified common themes including patient expectations, lack of knowledge of existing guidelines, and maintenance of education over time. Additional themes indicated differences in modifications needed by type of clinical setting. Adoption of public commitment was high, with 79% of providers signing a commitment log, and 84% received public commitment flair. Signing of public commitment posters rate was 62%, as several sites chose not to use this component. Acceptability, fidelity, and appropriateness were also measured. CONCLUSIONS We demonstrate that implementation science approaches can help address the problem of unnecessary antibiotic use in EDs and UCCs with high acceptability and adoption. Similar approaches could be used to tailor quality improvement interventions in these settings.
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Affiliation(s)
- Kabir Yadav
- Department of Emergency Medicine Harbor‐UCLA Medical Center TorranceCA
- Lundquist Institute Torrance CA
| | - Aubyn Stahmer
- Department of Psychiatry and Behavioral Sciences University of California‐Davis Sacramento CA
| | - Rakesh D. Mistry
- Department of Pediatrics Section of Emergency Medicine Children’s Hospital of Colorado Aurora CO
| | - Larissa May
- Department of Emergency Medicine University of California‐Davis Sacramento CA
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106
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Resman F. Antimicrobial stewardship programs; a two-part narrative review of step-wise design and issues of controversy Part I: step-wise design of an antimicrobial stewardship program. Ther Adv Infect Dis 2020; 7:2049936120933187. [PMID: 32612826 PMCID: PMC7307277 DOI: 10.1177/2049936120933187] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 05/11/2020] [Indexed: 12/27/2022] Open
Abstract
Regardless of one's opinion of antimicrobial stewardship programs (ASPs), it is hardly possible to work in hospital care and not be exposed to the term or its practical effects. Despite the term being relatively new, the number of publications in the field is vast, including several excellent reviews of general and specific aspects. Work in antimicrobial stewardship is complex, and includes not only aspects of infectious disease and microbiology, but also of epidemiology, genetics, behavioural psychology, systems science, economics and ethics, to name a few. This review aims to take several of these aspects and the scientific evidence of antimicrobial stewardship studies and merge them into two questions: How should we design ASPs based on what we know today? And which are the most essential unanswered questions regarding antimicrobial stewardship on a broader scale? This narrative review is written in two separate parts aiming to provide answers to the two questions. This first part is written as a step-wise approach to designing a stewardship intervention based on the pillars of unmet need, feasibility, scientific evidence and necessary core elements. It is written mainly as a guide to someone new to the field. It is sorted into five distinct steps: (a) focusing on designing aims; (b) assessing performance and local barriers to rational antimicrobial use; (c) deciding on intervention technique; (d) practical, tailored design including core element inclusion; and (e) evaluation and sustainability. The second part, published separately, formulates ten critical questions on controversies in the field of antimicrobial stewardship. It is aimed at clinicians and researchers with stewardship experience and strives to promote discussion, not to provide answers.
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Affiliation(s)
- Fredrik Resman
- Department of Translational Medicine, Clinical
Infection Medicine, Lund University, Rut Lundskogs Gata 3, Plan 6, Malmö, 20502,
Sweden
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107
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Agarwal M, Dick AW, Sorbero M, Mody L, Stone PW. Changes in US Nursing Home Infection Prevention and Control Programs From 2014 to 2018. J Am Med Dir Assoc 2020; 21:97-103. [PMID: 31888867 PMCID: PMC6948108 DOI: 10.1016/j.jamda.2019.10.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 10/22/2019] [Accepted: 10/27/2019] [Indexed: 01/23/2023]
Abstract
OBJECTIVE Burgeoning rates of antibiotic resistance have resulted in a shift in national focus to improve infection prevention and control programs in US nursing homes (NHs). We sought to evaluate the changes in nursing home infection prevention and control programs over time. DESIGN Retrospective comparative analysis of national nursing home survey data from 2014 and 2018. SETTING AND PARTICIPANTS We used survey data from 2 nationally representative samples of US nursing homes (945 NHs in 2014 and 888 in 2018). METHODS Three indices measuring antibiotic stewardship, outbreak control, and urinary tract infection prevention (ranging from 0 to 100) were developed to measure the change in infection prevention and control programs. Multivariable linear regression models were used to identify facility and infection preventionist characteristics associated with each index. Decomposition models were used to identify contributions of factors on the differences in each index over time. RESULTS From 2014 to 2018, we saw strengthening of antibiotic stewardship practices by 33 percentage points, outbreak control practices by 13 percentage points, and urinary tract infection prevention practices by 6 percentage points. Although we found several predictors of these improvements, much of the improvement was due to the difference in time. CONCLUSIONS AND IMPLICATIONS Policy mandates and greater national attention are likely important factors in improving nursing home infection prevention and control practices. Further work is needed to evaluate the effect of these programs on resident outcomes.
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Affiliation(s)
- Mansi Agarwal
- Columbia University School of Nursing, New York, NY.
| | | | | | - Lona Mody
- University of Michigan, Ann Arbor, MI
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108
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Shively NR, Buehrle DJ, Wagener MM, Clancy CJ, Decker BK. Improved Antibiotic Prescribing within a Veterans Affairs Primary Care System through a Multifaceted Intervention Centered on Peer Comparison of Overall Antibiotic Prescribing Rates. Antimicrob Agents Chemother 2019; 64:e00928-19. [PMID: 31685466 PMCID: PMC7187573 DOI: 10.1128/aac.00928-19] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 10/27/2019] [Indexed: 02/05/2023] Open
Abstract
Reducing inappropriate outpatient antibiotic use is an important national goal. Limited data exist on targeted education and peer comparison of overall antibiotic prescribing rates as an antimicrobial stewardship strategy. Primary care professionals (PCPs) from all seven clinics within our health care system were offered an education session, followed by monthly e-mails with their antibiotic prescribing rate, peer prescribing rates, and a system target. A pre-post analysis was conducted to compare prescribing rates during the intervention period (January to June 2017) to a seasonal baseline (January to June 2016) using a regression model. A random sample of prescriptions was reviewed for adherence to consensus guidelines. Educational sessions were attended by 68.5% (50/73) of PCPs. From the baseline to the intervention period, the mean rate of monthly antibiotic prescriptions declined from 76.9 to 49.5 per 1,000 office visits (35.6% reduction [P < 0.001]). Among reviewed cases, unnecessary antibiotic prescribing declined (58.8% [80/136] versus 38.9% [70/180]; 33.9% reduction [P = 0.0006]), and the rate of optimally prescribed antibiotics increased (19.9% [27/136] versus 30% [54/180]; 50.8% increase [P = 0.05]). If an antibiotic was indicated, there were no significant differences in prescribing of guideline-discordant agents (21.4% [12/56] versus 19.1% [21/110] [P = 0.8]) or guideline-concordant agents for a guideline-discordant duration (38.6% [17/44] versus 39.3% [35/89] [P = 1]). There were significant reductions in azithromycin and fluoroquinolone prescriptions (50.9% and 59.4% [P values of <0.001], respectively), but most prescriptions for these agents in the intervention period remained inappropriate. Initial education followed by monthly peer comparison of overall antibiotic prescribing rates reduced total and unnecessary antibiotic prescribing in primary care clinics.
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Affiliation(s)
- Nathan R Shively
- Division of Infectious Diseases, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Deanna J Buehrle
- Infectious Diseases Section, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Marilyn M Wagener
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Cornelius J Clancy
- Division of Infectious Diseases, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Infectious Diseases Section, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Brooke K Decker
- Division of Infectious Diseases, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Infectious Diseases Section, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
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109
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Saliba-Gustafsson EA, Dunberger Hampton A, Zarb P, Orsini N, Borg MA, Stålsby Lundborg C. Factors associated with antibiotic prescribing in patients with acute respiratory tract complaints in Malta: a 1-year repeated cross-sectional surveillance study. BMJ Open 2019; 9:e032704. [PMID: 31857311 PMCID: PMC6937012 DOI: 10.1136/bmjopen-2019-032704] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE To identify factors that influence general practitioners' (GPs') oral antibiotic prescribing for acute respiratory tract complaints (aRTCs) in Malta. DESIGN Repeated, cross-sectional surveillance. SETTING Maltese general practice; both public health centres and private GP clinics. PARTICIPANTS 30 GPs registered on the Malta Medical Council's Specialist Register and 3 GP trainees registered data of 4831 patients of all ages suffering from any aRTC. Data were collected monthly between May 2015 and April 2016 during predetermined 1-week periods. OUTCOME MEASURES The outcome of interest was antibiotic prescription (yes/no), defined as an oral antibiotic prescription issued for an aRTC during an in-person consultation, irrespective of the number of antibiotics given. The association between GP, practice and consultation-level factors, patient sociodemographic factors and patient health status factors, and antibiotic prescription was investigated. RESULTS The antibiotic prescription rate was 45.0%. Independent factors positively associated with antibiotic prescribing included female GP sex (OR 2.3, 95% CI 1.22 to 4.26), GP age with GPs ≥60 being the most likely (OR 34.7, 95% CI 14.14 to 84.98), patient age with patients ≥65 being the most likely (OR 2.3, 95% CI 1.71 to 3.18), number of signs and/or symptoms with patients having ≥4 being the most likely (OR 9.6, 95% CI 5.78 to 15.99), fever (OR 2.6, 95% CI 2.08 to 3.26), productive cough (OR 1.3, 95% CI 1.03 to 1.61), otalgia (OR 1.3, 95% CI 1.01 to 1.76), tender cervical nodes (OR 2.2, 95% CI 1.57 to 3.05), regular clients (OR 1.3, 95% CI 1.05 to 1.66), antibiotic requests (OR 4.8, 95% CI 2.52 to 8.99) and smoking (OR 1.4, 95% CI 1.13 to 1.71). Conversely, patients with non-productive cough (OR 0.3, 95% CI 0.26 to 0.41), sore throat (OR 0.6, 95% CI 0.53 to 0.78), rhinorrhoea (OR 0.3, 95% CI 0.23 to 0.36) or dyspnoea (OR 0.6, 95% CI 0.41 to 0.83) were less likely to receive an antibiotic prescription. CONCLUSION Antibiotic prescribing for aRTCs was high and influenced by a number of factors. Potentially inappropriate prescribing in primary care can be addressed through multifaceted interventions addressing modifiable factors associated with prescription. TRIAL REGISTRATION NUMBER NCT03218930.
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Affiliation(s)
- Erika A Saliba-Gustafsson
- Department of Global Public Health, Health Systems and Policy: Improving Use of Medicines, Karolinska Institutet, Stockholm, Sweden
| | - Alexandra Dunberger Hampton
- Department of Global Public Health, Health Systems and Policy: Improving Use of Medicines, Karolinska Institutet, Stockholm, Sweden
| | - Peter Zarb
- Department of Infection Prevention and Control, Mater Dei Hospital, Msida, Malta
| | - Nicola Orsini
- Department of Global Public Health, Social Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Michael A Borg
- Department of Infection Prevention and Control, Mater Dei Hospital, Msida, Malta
- Faculty of Medicine and Surgery, University of Malta, Msida, Malta
| | - Cecilia Stålsby Lundborg
- Department of Global Public Health, Health Systems and Policy: Improving Use of Medicines, Karolinska Institutet, Stockholm, Sweden
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110
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Longitudinal antibiotic prescribing trends among US dental specialists within a pharmacy benefits manager, 2013 through 2015. J Am Dent Assoc 2019; 150:846-853.e5. [PMID: 31561761 DOI: 10.1016/j.adaj.2019.05.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 05/19/2019] [Accepted: 05/22/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Reducing inappropriate antibiotic prescriptions (Rxs) is a major quality improvement initiative in the United States. Tracking antibiotic prescribing trends is 1 method of assessing improvement in antibiotic prescribing. The purpose of this study was to assess longitudinal antibiotic prescribing practices among dental specialists. METHODS This was a retrospective ecological longitudinal trend study. The authors calculated monthly systemic antibiotic Rx counts, and rates per 100,000 beneficiaries, from a pharmacy benefits manager in the United States from 2013 through 2015. The authors calculated average annual antibiotic Rx rates (AARs) for the 3-year study period. The authors used a quasi-Poisson regression model to analyze antibiotic Rx trends. The authors quantified seasonal trends, when present, via peak-to-trough ratios (PTTRs). RESULTS Dental specialists prescribed 2.4 million antibiotics to the cohort of 38 million insurance beneficiaries during the 3-year study period (AAR = 2,086 Rxs per 100,000 beneficiaries). Oral and maxillofacial surgeons prescribed the most antibiotics (1,172,104 Rxs; AAR = 1,018 Rxs per 100,000 beneficiaries), followed by periodontists (527,038 Rxs; AAR = 457 Rxs per 100,000 beneficiaries), and endodontists (447,362 Rxs; AAR = 388 Rxs per 100,000 beneficiaries). Longitudinal antibiotic prescribing trends were stable among all dental specialties in the regression models (P > .05). The authors observed substantial seasonal variation in antibiotic Rxs in 2 specialties: pediatric dentistry (PTTR, 1.18; 95% confidence interval, 1.13 to 1.25) and orthodontics and dentofacial orthopedics (PTTR, 1.41; 95% confidence interval, 1.21 to 1.71), with the highest rates of antibiotic Rxs in the spring and winter. CONCLUSIONS Antibiotic prescribing practices for dental specialists remained stable. The authors observed seasonal trends in 2 specialties. PRACTICAL IMPLICATIONS Public health efforts are needed improve antibiotic prescribing among dental specialties.
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111
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Peñalva G, Fernández-Urrusuno R, Turmo JM, Hernández-Soto R, Pajares I, Carrión L, Vázquez-Cruz I, Botello B, García-Robredo B, Cámara-Mestres M, Domínguez-Camacho JC, Aguilar-Carnerero MM, Lepe JA, de Cueto M, Serrano-Martino MC, Domínguez-Jiménez MC, Domínguez-Castaño A, Cisneros JM. Long-term impact of an educational antimicrobial stewardship programme in primary care on infections caused by extended-spectrum β-lactamase-producing Escherichia coli in the community: an interrupted time-series analysis. THE LANCET. INFECTIOUS DISEASES 2019; 20:199-207. [PMID: 31767423 DOI: 10.1016/s1473-3099(19)30573-0] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 07/11/2019] [Accepted: 09/05/2019] [Indexed: 01/09/2023]
Abstract
BACKGROUND There is little evidence on the ecological effect and sustainability of antimicrobial stewardship programmes (ASPs) in primary-care settings. We aimed to determine whether a multimodal, educational ASP would be sustainable in the long-term and reduce the incidence of infections caused by extended-spectrum β-lactamase-producing Escherichia coli in the community by optimising antibiotic use. METHODS We did this quasi-experimental intervention study in 214 primary health centres of four primary health-care districts in Andalusia, Spain. Local multidisciplinary teams, comprised of general practitioners, paediatricians, primary-care pharmacists, and epidemiologists, were created in each district and implemented a multimodal, education-based ASP. The core activity of the programme consisted of regular one-to-one educational interviews between a reference interviewing physician and prescribing physicians from each centre on the appropriateness of their most recent (same or preceding day) antibiotic prescriptions based on a structured questionnaire. Appropriate prescribing was defined as compliance of all checklist items with the reference guidelines. An average of five educational interviews were scheduled per prescriber per study year. We did an interrupted time-series analysis to assess the effect of the intervention on quarterly antibiotic use (prescription and collection by the patient) and quality of prescriptions (as defined daily doses per 1000 inhabitants per day) and incidence per 1000 inhabitants of E coli producing extended-spectrum β-lactamase (ESBL) isolated from urine samples. FINDINGS The study was done between January, 2012, and December, 2017, in a pre-intervention period of 2012-13 and an intervention period of 2014-17. Throughout the study period, there were 1387 physicians (1116 general practicioners and 271 paediatricians) in the included health centres serving a mean population of 1 937 512 people (299 331 children and 1 638 181 adults). 24 150 educational interviews were done over the 4 years. Inappropriate antibiotic prescribing was identified in 1794 (36·5%) of 4917 educational interviews in 2014 compared with 1793 (26·9%) of 6665 in 2017 (p<0·0001). The intervention was associated with a sustained reduction in the use of ciprofloxacin (relative effect -15·9%, 95% CI -23·9 to -8·0) and cephalosporins (-22·6%, -35·9 to -9·2), and a sustained increase in the use of amoxicillin (22·2%, 6·4 to 38·0) and fosfomycin trometamol (6·1%, 2·6 to 9·6). The incidence density of ESBL-producing E coli decreased by -0·028 cases per 1000 inhabitants (95% CI -0·034 to -0·021) after the start of the programme, reversing the pre-intervention increase and leading to a relative reduction of -65·6% (-68·2 to -63·0) 4 years later. INTERPRETATION Our data suggest that implementation of a multimodal ASP in primary care that is based on individual educational interviews improves the use of antibiotics and results in a sustained significant reduction of infections by ESBL-producing E coli in the community. This information should encourage the implementation of ASPs in primary care. FUNDING Instituto de Salud Carlos III, Spanish Government (PI14/01523).
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Affiliation(s)
- Germán Peñalva
- Department of Infectious Diseases, Microbiology and Preventive Medicine, Institute of Biomedicine of Seville, University Hospital Virgen del Rocío, Spanish National Research Council, University of Seville, Spain
| | | | | | - Rocío Hernández-Soto
- Primary Health-care District Aljarafe-Sevilla Norte, Mairena del Aljarafe, Seville, Spain
| | | | - Lucía Carrión
- Primary Health-care District Huelva-Costa, Huelva, Spain; Primary Health-care District Huelva-Condado-Campiña, La Palma del Condado, Huelva, Spain
| | | | - Blanca Botello
- Primary Health-care District Huelva-Condado-Campiña, La Palma del Condado, Huelva, Spain
| | - Beatriz García-Robredo
- Promotion of Rational Use of Medicines Department, Andalusian Health Service, Seville, Spain
| | | | | | | | - José Antonio Lepe
- Department of Infectious Diseases, Microbiology and Preventive Medicine, Institute of Biomedicine of Seville, University Hospital Virgen del Rocío, Spanish National Research Council, University of Seville, Spain
| | | | | | | | | | - José Miguel Cisneros
- Department of Infectious Diseases, Microbiology and Preventive Medicine, Institute of Biomedicine of Seville, University Hospital Virgen del Rocío, Spanish National Research Council, University of Seville, Spain.
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Redding LE, Cole SD. Posters Have Limited Utility in Conveying a Message of Antimicrobial Stewardship to Pet Owners. Front Vet Sci 2019; 6:421. [PMID: 31824973 PMCID: PMC6883349 DOI: 10.3389/fvets.2019.00421] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 11/08/2019] [Indexed: 01/02/2023] Open
Abstract
Pet owners frequently administer antimicrobials to their pets and therefore have an important role to play in promoting antimicrobial stewardship in veterinary medicine. However, best methods of educating pet owners about antimicrobial stewardship have yet to be defined. While visual materials such as brochures and posters are often used in health promotion campaigns, their effectiveness in veterinary medicine is unknown. The objective of this study was to determine whether pet owners noticed and retained the message of a poster with an antimicrobial stewardship message placed in veterinary clinic exam rooms. A total of 111 pet owners from five veterinary clinics (three general practices, two low-cost clinics) in the greater Philadelphia area participated in the study. Participants completed a survey asking whether they noticed the poster and if they could paraphrase its message. In a follow-up survey, an antibiotic knowledge score was calculated from answers to questions assessing their knowledge of the poster message. Baseline knowledge was assessed by asking participants to define antibiotic resistance. At the end of the study, veterinarians at participating clinics were interviewed about their experiences with the poster. Only 51 (46.4%) participants noticed the poster, and only 11 (9.9%) could partially or completely reproduce its message. No demographic or clinic-level factors were significantly associated with noticing the poster or recalling its message. Antibiotic knowledge scores were highly correlated (ρ = 0.87, p < 0.001) with baseline knowledge and not affected by viewing the poster (p = 0.955). Veterinarians expressed skepticism that the poster was effective in conveying a message of judicious antibiotic use to clients and noted no difference in the frequency with which they discussed antibiotic resistance or felt pressured to prescribe antibiotics by their clients. Posters alone will likely have limited impact in conveying a message of judicious antibiotic use to pet owners. However, they might be useful as part of an active, multi-modal education strategy, especially if complemented by veterinarian actions.
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Affiliation(s)
- Laurel E Redding
- School of Veterinary Medicine, University of Pennsylvania, Kennett Square, PA, United States
| | - Stephen D Cole
- School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, United States
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Abstract
Antimicrobial stewardship improves patient care and reduces antimicrobial resistance, inappropriate use, and adverse outcomes. Despite high-profile mandates for antimicrobial stewardship programs across the healthcare continuum, descriptive data, and recommendations for dedicated resources, including appropriate physician, pharmacist, data analytics, and administrative staffing support, are not robust. This review summarizes the current literature on antimicrobial stewardship staffing and calls for the development of minimum staffing recommendations.
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Efficacy of educational intervention on reducing the inappropriate use of oral third-generation cephalosporins. Infection 2019; 47:1037-1045. [PMID: 31605309 DOI: 10.1007/s15010-019-01362-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 09/30/2019] [Indexed: 12/30/2022]
Abstract
PURPOSE This study aimed to evaluate the efficacy of an educational intervention on reducing the inappropriate use of oral third-generation cephalosporins, the prevalence of resistant bacteria, and clinical outcomes. METHODS A before-after study was conducted to compare the data for 1 year before and after intervention at a Japanese university hospital. Educational intervention included lectures for all medical staff on oral antibiotics and educational meetings with each medical department. The primary outcome was the use of oral third-generation cephalosporins in inpatients as measured by the monthly median days of therapy (DOTs) per 1000 patient days. Secondary outcomes included the use of each oral antibiotic in inpatients and outpatients, proportion of β-lactamase-nonproducing ampicillin-resistant Haemophilus influenzae (BLNAR), penicillin-resistant Streptococcus pneumoniae (PRSP) and extended-spectrum β-lactamase producing Escherichia coli (ESBLEC), the incidence of hospital-acquired Clostridioides difficile infection (HA-CDI), and hospital mortality. RESULTS The use of oral third-generation cephalosporins in inpatients was significantly decreased after intervention [DOTs (interquartile range): 24.2 (23.5-25.1) vs. 3.7 (0.0-7.1), P < 0.001], and the value in outpatients was also decreased significantly. The use of fluoroquinolones and macrolides did not increase after intervention. The proportion of BLNAR, PRSP and ESBLEC did not change significantly during the study period. The incidence of HA-CDI was significantly decreased, and hospital mortality did not change after intervention. CONCLUSION Educational intervention was effective in reducing the use of oral third-generation cephalosporins without increasing the use of broad-spectrum antibiotics and worsening clinical outcome. The prevalence of resistant bacteria did not change during the study period.
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Lorencatto F, Charani E, Sevdalis N, Tarrant C, Davey P. Driving sustainable change in antimicrobial prescribing practice: how can social and behavioural sciences help? J Antimicrob Chemother 2019; 73:2613-2624. [PMID: 30020464 DOI: 10.1093/jac/dky222] [Citation(s) in RCA: 88] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Addressing the growing threat of antimicrobial resistance is, in part, reliant on the complex challenge of changing human behaviour-in terms of reducing inappropriate antibiotic use and preventing infection. Whilst there is no 'one size fits all' recommended behavioural solution for improving antimicrobial stewardship, the behavioural and social sciences offer a range of theories, frameworks, methods and evidence-based principles that can help inform the design of behaviour change interventions that are context-specific and thus more likely to be effective. However, the state-of-the-art in antimicrobial stewardship research and practice suggests that behavioural and social influences are often not given due consideration in the design and evaluation of interventions to improve antimicrobial prescribing. In this paper, we discuss four potential areas where the behavioural and social sciences can help drive more effective and sustained behaviour change in antimicrobial stewardship: (i) defining the problem in behavioural terms and understanding current behaviour in context; (ii) adopting a theory-driven, systematic approach to intervention design; (iii) investigating implementation and sustainability of interventions in practice; and (iv) maximizing learning through evidence synthesis and detailed intervention reporting.
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Affiliation(s)
| | - Esmita Charani
- NIHR Health Protection Research Unit in Healthcare Acquired Infection and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, London, UK
| | - Nick Sevdalis
- Centre for Implementation Science, Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Carolyn Tarrant
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Peter Davey
- Division of Population Health Sciences, School of Medicine, University of Dundee, Dundee, Scotland, UK
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Schneider S, Salm F, Vincze S, Moeser A, Petruschke I, Schmücker K, Ludwig N, Hanke R, Schröder C, Gropmann A, Behnke M, Lübke-Becker A, Wieler LH, Hagel S, Pletz MW, Gensichen J, Gastmeier P. Perceptions and attitudes regarding antibiotic resistance in Germany: a cross-sectoral survey amongst physicians, veterinarians, farmers and the general public. J Antimicrob Chemother 2019; 73:1984-1988. [PMID: 29590400 DOI: 10.1093/jac/dky100] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 03/02/2018] [Indexed: 11/14/2022] Open
Abstract
Background Drivers of antibiotic (AB) resistance (ABR) include outpatient treatment, hospital care and animal husbandry. During the first phase of the One Health project RAI (Responsible Antibiotic Use via Information and Communication) surveys were conducted in these sectors. Objectives To compare perceptions and attitudes towards ABR among general practitioners (GPs), hospital physicians, veterinarians, pig farmers and the general public. Methods Cross-sectional questions on AB use and ABR were integrated in group-specific surveys of GPs, hospital physicians, veterinarians, pig farmers and the German general population. Results A total of 1789 participants (340 GPs, 170 hospital physicians, 215 pig farmers, 60 veterinarians and 1004 members of the public) responded. Each group tended to identify drivers of ABR as being from outside its own area of activity. Guidelines were shown to be an important information source for AB therapy for all prescriber groups, but the frequency of routine use differed (39% of GPs, 65% of hospital physicians and 53% of veterinarians). Regarding further information sources, hospital physicians preferred smartphone apps and e-learning, GPs preferred non-sponsored training and veterinarians preferred multidisciplinary networks and e-learning. Farmers were predominantly satisfied with existing solutions. Farmers had three times better basic knowledge of ABR and knew twice as many people with MDR organism problems than the general public. They also received information on ABR more often from their veterinarians than patients did from their doctors. Conclusions This study reveals considerable differences in perceptions and attitudes to ABR among the groups investigated. The results can help to tailor future interventions. Furthermore, they promote mutual understanding and thus support the One Health approach.
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Affiliation(s)
- Sandra Schneider
- Institute of Hygiene and Environmental Medicine, Charité University Medical Center Berlin, Hindenburgdamm 27, D-12203 Berlin, Germany
| | - Florian Salm
- Institute of Hygiene and Environmental Medicine, Charité University Medical Center Berlin, Hindenburgdamm 27, D-12203 Berlin, Germany
| | - Szilvia Vincze
- Institute of Microbiology and Epizootics, Department of Veterinary Medicine at the Freie Universität Berlin, Robert-von-Ostertag-Str. 7-13, D-14163 Berlin, Germany
| | - Anne Moeser
- Center for Infectious Diseases and Infection Control, Jena University Hospital, Am Klinikum 1, D-07747 Jena, Germany
| | - Inga Petruschke
- Institute of General Practice and Family Medicine, Jena University Hospital, Bachstrasse 18, D-07743 Jena, Germany
| | - Katja Schmücker
- Institute of General Practice and Family Medicine, Jena University Hospital, Bachstrasse 18, D-07743 Jena, Germany
| | - Norman Ludwig
- Lindgrün GmbH, Cuxhavener Strasse 12, D-10555 Berlin, Germany
| | - Regina Hanke
- Institute of Hygiene and Environmental Medicine, Charité University Medical Center Berlin, Hindenburgdamm 27, D-12203 Berlin, Germany.,Lindgrün GmbH, Cuxhavener Strasse 12, D-10555 Berlin, Germany
| | - Christin Schröder
- Institute of Hygiene and Environmental Medicine, Charité University Medical Center Berlin, Hindenburgdamm 27, D-12203 Berlin, Germany
| | - Alexander Gropmann
- Institute of Hygiene and Environmental Medicine, Charité University Medical Center Berlin, Hindenburgdamm 27, D-12203 Berlin, Germany
| | - Michael Behnke
- Institute of Hygiene and Environmental Medicine, Charité University Medical Center Berlin, Hindenburgdamm 27, D-12203 Berlin, Germany
| | - Antina Lübke-Becker
- Institute of Microbiology and Epizootics, Department of Veterinary Medicine at the Freie Universität Berlin, Robert-von-Ostertag-Str. 7-13, D-14163 Berlin, Germany
| | - Lothar H Wieler
- Institute of Microbiology and Epizootics, Department of Veterinary Medicine at the Freie Universität Berlin, Robert-von-Ostertag-Str. 7-13, D-14163 Berlin, Germany.,Robert Koch Institute, PO Box 65 02 61, D-13302 Berlin, Germany
| | - Stefan Hagel
- Center for Infectious Diseases and Infection Control, Jena University Hospital, Am Klinikum 1, D-07747 Jena, Germany
| | - Mathias W Pletz
- Center for Infectious Diseases and Infection Control, Jena University Hospital, Am Klinikum 1, D-07747 Jena, Germany
| | - Jochen Gensichen
- Institute of General Practice and Family Medicine, Jena University Hospital, Bachstrasse 18, D-07743 Jena, Germany
| | - Petra Gastmeier
- Institute of Hygiene and Environmental Medicine, Charité University Medical Center Berlin, Hindenburgdamm 27, D-12203 Berlin, Germany
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O'Keefe C, Thompson A, McKenzie D, Lee K. Concordance with antibiotic guidelines in Australian primary care: A retrospective study of prior-to-hospital therapy. Int J Clin Pract 2019; 73:e13427. [PMID: 31573741 DOI: 10.1111/ijcp.13427] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 08/12/2019] [Accepted: 09/21/2019] [Indexed: 11/30/2022] Open
Abstract
Background Appropriate antibiotic prescribing improves patient outcomes and mitigates antimicrobial resistance. As the majority of antibiotics are used in the community, rational prescribing in this setting is of paramount importance. Objectives We aimed to (1) evaluate the concordance of community antibiotic prescribing with guidelines for three common infection types among patients who presented to hospital, and (2) identify relationships between guideline concordance and patient-related factors. Methods Medical records were evaluated from the Royal Hobart Hospital (Tasmania, Australia) for patients presenting with respiratory tract, urinary tract or skin and soft tissue infections within a 12-month period. Prior-to-hospital antibiotic therapy was assessed for concordance with prescribing guidelines based on presenting diagnosis. Concordance was assessed against first-line recommendations in the Australian Therapeutic Guidelines - Antibiotic, based on drug choice, dose, frequency and patient factors. Descriptive statistics were performed to address Objective 1. Multivariate logistic regressions were conducted to address Objective 2 with the following independent variables: infection type, age, allergies, diabetes status, gender and residential setting. Results A total of 285 patient records were eligible for data analysis; 28.8% (n = 82) were fully guideline concordant. The most common reason for non-concordance was inappropriate drug choice (n = 143, 50.2%). Patients with the following characteristics were less likely to receive concordant therapy: diabetes (OR = 0.3, 95% CI 0.1-0.8, P = .02) and increasing age (OR = 0.99, 95% CI 0.98-1.00, P = .04). Conclusions Almost three-quarters of patients received community-initiated antibiotic therapy that was not fully guideline concordant. Antimicrobial stewardship interventions are urgently needed to improve guideline concordance for community-initiated antibiotic therapy.
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Affiliation(s)
- Caitlan O'Keefe
- Pharmacy Department, Tasmanian Health Service, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Angus Thompson
- Division of Pharmacy, School of Medicine, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Duncan McKenzie
- Pharmacy Department, Tasmanian Health Service, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Kenneth Lee
- Division of Pharmacy, School of Medicine, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
- Faculty of Health and Medical Sciences, Division of Pharmacy, School of Allied Health, University of Western Australia, Crawley, Western Australia, Australia
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Cole KA, Rivard KR, Dumkow LE. Antimicrobial Stewardship Interventions to Combat Antibiotic Resistance: an Update on Targeted Strategies. Curr Infect Dis Rep 2019; 21:33. [PMID: 31473861 DOI: 10.1007/s11908-019-0689-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Overutilization of antimicrobials is a known contributor to the development of antimicrobial resistance, which is a threat to global health. The goal of antimicrobial stewardship programs (ASPs) is to implement targeted interventions to reduce inappropriate antimicrobial prescribing and prevent development of antimicrobial resistance. We aim to review recently published literature focused on five categories of ASP interventions that have demonstrated success in optimizing appropriate antimicrobial use, improving patient outcomes, and fighting antimicrobial resistance. RECENT FINDINGS In the past year, ASP interventions in the published literature have focused on minimizing duration of antimicrobial therapy for infectious syndromes, implementing novel methods for performing prospective audit and feedback, utilizing microbiology laboratory or rapid diagnostic tests to expedite diagnosis, leveraging clinical decision support and electronic medical record tools, and performing penicillin allergy assessment. While the majority of studies assessing ASP interventions do not assess changes in antimicrobial resistance, outcomes demonstrating improved appropriate antibiotic use have been used as a surrogate. Successful ASPs should seek to implement and evaluate novel interventions targeting improvement in antimicrobial prescribing. Such interventions are of critical importance to prevent further growth of antimicrobial resistance.
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Affiliation(s)
- Kelli A Cole
- Department of Pharmacy Services, University of Toledo Medical Center, 3000 Arlington Ave. MS 1013, Toledo, OH, 43614, USA.
| | - Kaitlyn R Rivard
- Department of Pharmacy, Cleveland Clinic, 9500 Euclid Avenue (Hb-105), Cleveland, OH, 44195, USA
| | - Lisa E Dumkow
- Department of Pharmacy Services, Mercy Health Saint Mary's, 200 Jefferson SE, Grand Rapids, MI, 49503, USA.
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White AT, Clark CM, Sellick JA, Mergenhagen KA. Antibiotic stewardship targets in the outpatient setting. Am J Infect Control 2019; 47:858-863. [PMID: 30862373 DOI: 10.1016/j.ajic.2019.01.027] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 01/31/2019] [Accepted: 01/31/2019] [Indexed: 01/30/2023]
Abstract
BACKGROUND Outpatient prescriptions comprise 60% of antibiotic use. This study prospectively identified inappropriate antibiotic use enabling a focused approach to outpatient antimicrobial stewardship. METHODS Outpatients at the Veterans Affairs Western New York Healthcare System were identified via an electronic antibiotic alert from June 2017 to September 2017. Descriptive statistics and multivariable logistic regression identified stewardship targets. RESULTS Of the 1,063 patients, 40% of antibiotic prescriptions were not indicated. Urinary tract infections (21%), bronchitis (20%), skin structure infections (17%), and sinusitis (10%) were common causes of inappropriate antibiotic use. Azithromycin (37%) was prescribed unnecessarily most often, followed by ciprofloxacin (16%), amoxicillin/clavulanate (13%), and cephalexin (12%). The correct drug was chosen in 52%, dose in 81%, and duration in 75% of patients. When the antibiotic was indicated, the correct drug was 2.9 times more likely to be prescribed and 2 times more likely to have the correct duration and receive care in the emergency room. DISCUSSION Focusing on 4 drugs; amoxicillin/clavulanate, azithromycin, ciprofloxacin, and cephalexin accounted for 80% of unnecessary drug use. This study provides a guide to concentrate efforts during implementation of an outpatient stewardship program. CONCLUSIONS Poor antibiotic prescribing was found in the outpatient setting. This study identifies areas for improvement via stewardship.
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Affiliation(s)
- Alexis T White
- Department of Pharmacy, Veterans Affairs Western New York Healthcare System, Buffalo, NY
| | - Collin M Clark
- Department of Pharmacy, Veterans Affairs Western New York Healthcare System, Buffalo, NY
| | - John A Sellick
- Department of Medicine, Veterans Affairs Western New York Healthcare System, Buffalo, NY; Department of Medicine, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY
| | - Kari A Mergenhagen
- Department of Pharmacy, Veterans Affairs Western New York Healthcare System, Buffalo, NY.
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Rowe TA, Linder JA. Novel approaches to decrease inappropriate ambulatory antibiotic use. Expert Rev Anti Infect Ther 2019; 17:511-521. [DOI: 10.1080/14787210.2019.1635455] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Theresa A. Rowe
- General Internal Medicine and Geriatrics, Northwestern University of Feinberg School of Medicine, Chicago, IL, USA
| | - Jeffrey A. Linder
- General Internal Medicine and Geriatrics, Northwestern University of Feinberg School of Medicine, Chicago, IL, USA
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McNulty C, Hawking M, Lecky D, Jones L, Owens R, Charlett A, Butler C, Moore P, Francis N. Effects of primary care antimicrobial stewardship outreach on antibiotic use by general practice staff: pragmatic randomized controlled trial of the TARGET antibiotics workshop. J Antimicrob Chemother 2019. [PMID: 29514268 PMCID: PMC5909634 DOI: 10.1093/jac/dky004] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Objectives To determine whether local trainer-led TARGET antibiotic interactive workshops improve antibiotic dispensing in general practice. Methods Using a McNulty–Zelen-design randomized controlled trial within three regions of England, 152 general practices were stratified by clinical commissioning group, antibiotic dispensing rate and practice patient list size, then randomly allocated to intervention (offered TARGET workshop that incorporated a presentation, reflection on antibiotic data, promotion of patient and general practice (GP) staff resources, clinical scenarios and action planning, 73 practices) or control (usual practice, 79 practices). The primary outcome measure was total oral antibiotic items dispensed/1000 patients for the year after the workshop (or pseudo-workshop date for controls), adjusted for the previous year’s dispensing. Results Thirty-six (51%) intervention practices (166 GPs, 51 nurses and 101 other staff) accepted a TARGET workshop invitation. In the ITT analysis total antibiotic dispensing was 2.7% lower in intervention practices (95% CI −5.5% to 1%, P = 0.06) compared with controls. Dispensing in intervention practices was 4.4% lower for amoxicillin/ampicillin (95% CI 0.6%–8%, P = 0.02); 5.6% lower for trimethoprim (95% CI 0.7%–10.2%, P = 0.03); and a non-significant 7.1% higher for nitrofurantoin (95% CI −0.03 to 15%, P = 0.06). The Complier Average Causal Effect (CACE) analysis, which estimates impact in those that comply with assigned intervention, indicated 6.1% (95% CI 0.2%–11.7%, P = 0.04) lower total antibiotic dispensing in intervention practices and 11% (95% CI 1.6%–19.5%, P = 0.02) lower trimethoprim dispensing. Conclusions This study within usual service provision found that TARGET antibiotic workshops can help improve antibiotic use, and therefore should be considered as part of any national antimicrobial stewardship initiatives. Additional local facilitation will be needed to encourage all general practices to participate.
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Affiliation(s)
- Cliodna McNulty
- Primary Care Unit, Public Health England, Gloucester Royal Hospital, Great Western Road, Gloucester GL1 3NN, UK
| | - Meredith Hawking
- Centre for Primary Care and Public Health, Bart's and the London School of Medicine and Dentistry, Queen Mary University, Yvonne Carter Building, 58 Turner Street, London E1 2AB, UK
| | - Donna Lecky
- Primary Care Unit, Public Health England, Gloucester Royal Hospital, Great Western Road, Gloucester GL1 3NN, UK
| | - Leah Jones
- Primary Care Unit, Public Health England, Gloucester Royal Hospital, Great Western Road, Gloucester GL1 3NN, UK
| | - Rebecca Owens
- Primary Care Unit, Public Health England, Gloucester Royal Hospital, Great Western Road, Gloucester GL1 3NN, UK
| | - André Charlett
- Statistics Unit Public Health England, 61 Colindale Avenue, London NW9 5EQ, UK
| | - Chris Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Rd, Oxford OX2 6GG, UK
| | - Philippa Moore
- Gloucestershire Hospitals NHS Foundation Trust, Great Western Road, Gloucester GL1 3NN, UK
| | - Nick Francis
- Division of Population Medicine, Cardiff University School of Medicine, Neuadd Meirionnydd, Heath Park, Cardiff CF14 4YS, UK
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Qualitative Analysis of Primary Care Provider Prescribing Decisions for Urinary Tract Infections. Antibiotics (Basel) 2019; 8:antibiotics8020084. [PMID: 31248119 PMCID: PMC6627108 DOI: 10.3390/antibiotics8020084] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 06/13/2019] [Accepted: 06/14/2019] [Indexed: 12/26/2022] Open
Abstract
Inappropriate choices and durations of therapy for urinary tract infections (UTI) are a common and widespread problem. In this qualitative study, we sought to understand why primary care providers (PCPs) choose certain antibiotics or durations of treatment and the sources of information they rely upon to guide antibiotic-prescribing decisions. We conducted semi-structured interviews with 18 PCPs in two family medicine clinics focused on antibiotic-prescribing decisions for UTIs. Our interview guide focused on awareness and familiarity with guidelines (knowledge), acceptance and outcome expectancy (attitudes), and external barriers. We followed a six-phase approach to thematic analysis, finding that many PCPs believe that fluoroquinolones achieve more a rapid and effective control of UTI symptoms than trimethoprim-sulfamethoxazole or nitrofurantoin. Most providers were unfamiliar with fosfomycin as a possible first-line agent for the treatment of acute cystitis. PCPs may be misled by advanced patient age, diabetes, and recurrent UTIs to make inappropriate choices for the treatment of acute cystitis. For support in clinical decision making, few providers relied on guidelines, preferring instead to have decision support embedded in the electronic medical record. Knowing the PCPs’ knowledge gaps and preferred sources of information will guide the development of a primary care-specific antibiotic stewardship intervention for acute cystitis.
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Gong CL, Zangwill KM, Hay JW, Meeker D, Doctor JN. Behavioral Economics Interventions to Improve Outpatient Antibiotic Prescribing for Acute Respiratory Infections: a Cost-Effectiveness Analysis. J Gen Intern Med 2019; 34:846-854. [PMID: 29740788 PMCID: PMC6544688 DOI: 10.1007/s11606-018-4467-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 03/06/2018] [Accepted: 04/13/2018] [Indexed: 01/13/2023]
Abstract
BACKGROUND Behavioral economics interventions have been shown to effectively reduce the rates of inappropriate antibiotic prescriptions for acute respiratory infections (ARIs). OBJECTIVE To determine the cost-effectiveness of three behavioral economic interventions designed to reduce inappropriate antibiotic prescriptions for ARIs. DESIGN Thirty-year Markov model from the US societal perspective with inputs derived from the literature and CDC surveillance data. SUBJECTS Forty-five-year-old adults with signs and symptoms of ARI presenting to a healthcare provider. INTERVENTIONS (1) Provider education on guidelines for the appropriate treatment of ARIs; (2) Suggested Alternatives, which utilizes computerized clinical decision support to suggest non-antibiotic treatment choices in lieu of antibiotics; (3) Accountable Justification, which mandates free-text justification into the patient's electronic health record when antibiotics are prescribed; and (4) Peer Comparison, which sends a periodic email to prescribers about his/her rate of inappropriate antibiotic prescribing relative to clinician colleagues. MAIN MEASURES Discounted costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios. KEY RESULTS Each intervention has lower costs but higher QALYs compared to provider education. Total costs for each intervention were $178.21, $173.22, $172.82, and $172.52, and total QALYs were 14.68, 14.73, 14.74, and 14.74 for the control, Suggested Alternatives, Accountable Justification, and Peer Comparison groups, respectively. Results were most sensitive to the quality-of-life of the uninfected state, and the likelihood and costs for antibiotic-associated adverse events. CONCLUSIONS Behavioral economics interventions can be cost-effective strategies for reducing inappropriate antibiotic prescriptions by reducing healthcare resource utilization.
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Affiliation(s)
- Cynthia L Gong
- University of Southern California Leonard D. Schaeffer Center for Health Policy & Economics, Los Angeles, CA, USA.
| | - Kenneth M Zangwill
- Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Los Angeles, CA, USA
| | - Joel W Hay
- University of Southern California Leonard D. Schaeffer Center for Health Policy & Economics, Los Angeles, CA, USA
| | - Daniella Meeker
- University of Southern California Leonard D. Schaeffer Center for Health Policy & Economics, Los Angeles, CA, USA.,University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Jason N Doctor
- University of Southern California Leonard D. Schaeffer Center for Health Policy & Economics, Los Angeles, CA, USA
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Huttner B, Saam M, Moja L, Mah K, Sprenger M, Harbarth S, Magrini N. How to improve antibiotic awareness campaigns: findings of a WHO global survey. BMJ Glob Health 2019; 4:e001239. [PMID: 31179029 PMCID: PMC6528771 DOI: 10.1136/bmjgh-2018-001239] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Revised: 01/15/2019] [Accepted: 01/19/2019] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION We aimed to examine the characteristics of antibiotic awareness campaigns (AAC) conducted on a national or regional level since 2010. METHODS In October 2016, the WHO invited stakeholders involved in the planning or conduct of AACs to answer a web questionnaire. We solicited general information about the characteristics of the AAC, with a particular focus on key messages supporting optimal use of antibiotics. RESULTS Stakeholders in 93 countries were contacted and 55 countries responded. Overall, 60 AACs from 16 low/middle-income countries (LMIC) and 31 high-income countries were identified. Forty-five campaigns (75%) were conducted on a national level and most of them (47/60; 78%) were organised by public health authorities and publicly funded. There were no major differences between LMICs and high-income countries in the types of key messages. The scientifically questionable 'Finish your prescription' slogan was used by 31 AACs (52%). A One Health approach was mentioned in 13/60 AACs (22%). Most messages were universally applicable; adaptation to locally prevalent public misconceptions was not systematic. The evaluation of the impact of campaigns was still incomplete, as only 18 AACs (30%) assessed their impact on antibiotic use. CONCLUSION For future AACs, it seems essential to base messages more rigorously on scientific evidence, context specificities and behavioural change theory. A new generation of messages that encourage first-choice use of narrow spectrum antibiotics is needed, reflecting international efforts to preserve broad spectrum antibiotic classes. Evaluation of the impact of AACs remains suboptimal.
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Affiliation(s)
- Benedikt Huttner
- Infection Control Program and Division of Infectious Diseases, World Health Organization Collaborating Centre on Patient Safety, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
- World Health Organization, Department of Essential Medicines and Health Products, World Health Organization, Geneva, Switzerland
| | - Mirko Saam
- Communications in Science, Geneva, Switzerland
| | - Lorenzo Moja
- World Health Organization, Department of Essential Medicines and Health Products, World Health Organization, Geneva, Switzerland
| | - Karen Mah
- World Health Organization, Antimicrobial Resistance Secretariat, Geneva, Switzerland
| | - Marc Sprenger
- World Health Organization, Antimicrobial Resistance Secretariat, Geneva, Switzerland
| | - Stephan Harbarth
- Infection Control Program and Division of Infectious Diseases, World Health Organization Collaborating Centre on Patient Safety, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Nicola Magrini
- World Health Organization, Department of Essential Medicines and Health Products, World Health Organization, Geneva, Switzerland
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Golding SE, Ogden J, Higgins HM. Shared Goals, Different Barriers: A Qualitative Study of UK Veterinarians' and Farmers' Beliefs About Antimicrobial Resistance and Stewardship. Front Vet Sci 2019; 6:132. [PMID: 31106216 PMCID: PMC6494936 DOI: 10.3389/fvets.2019.00132] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 04/09/2019] [Indexed: 01/21/2023] Open
Abstract
Although much research has investigated the drivers of inappropriate antimicrobial prescribing in human medicine, equivalent research in veterinary medicine is in its infancy. This qualitative study used a critical incident approach to explore farm veterinarians' (vets) and farmers' beliefs about antimicrobial use and antimicrobial stewardship. Semi-structured interviews were conducted with 13 vets and 12 farmers in the UK, who worked mostly with beef cattle, dairy cattle and sheep, but a minority also worked with pigs or poultry. An inductive thematic analysis was conducted to explore how vets and farmers understood their responsibilities toward stewardship and antimicrobial resistance (AMR) and to identify key similarities and differences between the professions. The analysis generated four themes: "A shared conflict between ideals and behaviour," "Barriers to stewardship: the vets' perspective," "Barriers to stewardship: the farmers' perspective," and "A shared ambivalence: ownership vs. other-blaming." Vets and farmers demonstrated good understanding of stewardship but their treatment decisions are not always aligned to stewardship principles. Various barriers to improving antimicrobial stewardship were discussed by vets and farmers, but they placed differing emphasis on specific barriers. Faced with these barriers and an awareness that antimicrobial usage is not always aligned to stewardship principles, vets and farmers expressed frustration and a sense of ambivalence toward stewardship, and also engaged in other-blaming for the problem of AMR. In conclusion, vets and farmers in this study seem motivated to be antimicrobial stewards but feel challenged by the day-to-day reality of their jobs; they experience ambivalence toward their responsibilities for AMR, which may negatively impact their motivation to always act as antimicrobial stewards. Successfully tackling AMR will require change at the individual-, group-, and societal-level. Future interventions to improve antimicrobial usage in livestock farming could be situated within a social ecological framework, where other-blaming between professions is seen as a result of the interplay between psychological and contextual factors. Other-blaming could be reduced using a social identity approach; a common ingroup identity could be created by encouraging vets and farmers to focus on their common goal, namely a shared desire to promote animal welfare through optimal antimicrobial stewardship.
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Affiliation(s)
- Sarah E. Golding
- Faculty of Health & Medical Sciences, School of Psychology, University of Surrey, Guildford, United Kingdom
| | - Jane Ogden
- Faculty of Health & Medical Sciences, School of Psychology, University of Surrey, Guildford, United Kingdom
| | - Helen M. Higgins
- Institute of Veterinary Science, University of Liverpool, Neston, United Kingdom
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Terahara F, Nishiura H. Fluoroquinolone consumption and Escherichia coli resistance in Japan: an ecological study. BMC Public Health 2019; 19:426. [PMID: 31014305 PMCID: PMC6480435 DOI: 10.1186/s12889-019-6804-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 04/11/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The frequency of antimicrobial resistance has steadily increased worldwide, induced by inappropriate use of antibiotics in a variety of settings. We analyzed the ecological correlation between fluoroquinolone consumption and levofloxacin resistance in Escherichia coli in Japan. METHODS We collected information on cases of E. coli resistant to levofloxacin in 2015-2016 in all 47 prefectures from the Japan Nosocomial Infections Surveillance system. Information on fluoroquinolone consumption was obtained from pharmaceutical sales data. To address potential confounding, we also collected information on the number of physicians, nurses, and medical facilities per 100,000 individuals. RESULTS We identified higher fluoroquinolone consumption and higher resistance in western prefectures, and lower consumption and resistance in eastern prefectures. Multivariate analysis identified a positive correlation between fluoroquinolone consumption and levofloxacin resistance in both 2015 and 2016. CONCLUSIONS Fluoroquinolone consumption and levofloxacin-resistant E. coli are potentially associated on a nationwide scale. The relationship between the two must be elucidated using additional studies with different epidemiological designs, so that any possible counter-measures, including alternative prescription, can be considered in the future.
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Affiliation(s)
- Fumitaka Terahara
- Graduate School of Medicine, Hokkaido University, Kita 15 Jo Nishi 7 Chome, Kita-ku, Sapporo-shi, Hokkaido 060-8638 Japan
- CREST, Japan Science and Technology Agency, Honcho 4-1-8, Kawaguchi, Saitama, 332-0012 Japan
| | - Hiroshi Nishiura
- Graduate School of Medicine, Hokkaido University, Kita 15 Jo Nishi 7 Chome, Kita-ku, Sapporo-shi, Hokkaido 060-8638 Japan
- CREST, Japan Science and Technology Agency, Honcho 4-1-8, Kawaguchi, Saitama, 332-0012 Japan
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Toward economic evaluation of the value of vaccines and other health technologies in addressing AMR. Proc Natl Acad Sci U S A 2019; 115:12911-12919. [PMID: 30559203 DOI: 10.1073/pnas.1717161115] [Citation(s) in RCA: 87] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
We discuss the need to make economic evaluations of vaccines antimicrobial resistance (AMR)-sensitive and ways to do so. Such AMR-sensitive evaluations can play a role in value-for-money comparisons of different vaccines within a national immunization program, or in comparisons of vaccine-centric and non-vaccine-centric technologies within an anti-AMR program. In general terms, incremental cost-effectiveness ratios and rates of return and their associated decision rules are unaltered by consideration of AMR-related value. The decision metrics need to have their various health, cost, and socioeconomic terms disaggregated into resistance-related subcategories, which in turn have to be measured carefully before they are reaggregated. The fundamental scientific challenges lie primarily in quantifying the causal impact of health technologies on resistance-related health outcomes, and secondarily in ascertaining the economic value of those outcomes. We emphasize the importance of evaluating vaccines in the context of other potentially complementary and substitutable nonvaccine technologies. Complementarity implies that optimal spending on each set of interventions is positive, and substitutability implies that the ratio of spending will depend on relative value for money. We exemplify this general point through a qualitative discussion of the complementarities and (especially the) substitutability between pneumococcal conjugate vaccines and antimicrobial stewardship and between research and development (R&D) of a gonorrhea vaccine versus R&D of a gonorrhea antibiotic. We propose a roadmap for future work, which includes quantifying the causal effects of vaccination and other health technologies on short-term and long-term resistance-related outcomes, measuring the health-sector costs and broader socioeconomic consequences of resistance-related mortality and morbidity, and evaluating vaccines in the context of nonvaccine complements and substitutes.
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Abstract
Opioid analgesics and antibiotics prescribed by dentists is a useful and cost-effective measure when prescribed appropriately. Common dental conditions are best managed by extracting the offending tooth, restoring the tooth with an appropriate filling material, performing root canal therapy, and/or fabricating a prosthesis for the edentulous space. Unnecessary prescription of opioid analgesics and antibiotics to treat dental pain and bacterial infection is a growing public health concern. This article highlights the state of the literature on opioid analgesic and antibiotic prescribing practices in dentistry, the impact of opioid analgesic overdose, and prevention strategies to reduce opioid analgesics and antibiotic overprescription.
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130
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Wang N, Athans V, Neuner E, Bollinger J, Spinner M, Brizendine K. A pharmacist-driven antimicrobial stewardship intervention targeting cytomegalovirus viremia in ambulatory solid organ transplant recipients. Transpl Infect Dis 2018; 20:e12991. [PMID: 30184302 DOI: 10.1111/tid.12991] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 08/02/2018] [Accepted: 08/20/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND There is a growing need for robust antimicrobial stewardship interventions in both ambulatory and solid organ transplant (SOT) populations. METHODS A retrospective quasi-experiment was conducted to evaluate the impact of a pharmacist-driven antimicrobial stewardship intervention targeting cytomegalovirus (CMV) viremia in ambulatory SOT recipients. The intervention consisted of (a) real-time CMV DNA surveillance and result notification conducted by the pharmacist and (b) recommendations for the optimization of drug therapy provided at the time of result notification. The intervention period was compared to a pre-intervention period of usual care. Of 431 adult SOT recipients who had an initial quantifiable CMV viral load in the ambulatory setting, 185 received antiviral induction therapy and were included for analysis. RESULTS Significantly fewer patients in the intervention period reached a CMV viral load >10 000 IU/mL immediately prior to treatment (10.6% vs 27.3%; P = 0.004), and a significantly greater proportion of patients in the intervention period achieved CMV eradication at 21 days (84.5% vs 71.7%; P = 0.038). Additional differences favoring the intervention period were antiviral initiation within 5 days of the first quantifiable CMV DNA (62.4% vs 55.0%; P = 0.02) and time-to-CMV eradication (25.5 vs 28.9 days; P = 0.003). Although not significant, there were also numerical reductions in CMV-related hospital admissions (11.9% vs 19.0%; P = 0.188) and CMV disease (5.9% vs 12.0%; P = 0.151) during the intervention period, as well as fewer episodes of CMV resistance at 1-year (2.3% vs 4.0%; P = 0.689). CONCLUSION Together, these findings suggest a potential role for pharmacist involvement in CMV surveillance and treatment optimization in ambulatory SOT recipients.
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Affiliation(s)
- Nan Wang
- Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio
| | | | | | | | | | - Kyle Brizendine
- Department of Infectious Diseases, Cleveland Clinic, Cleveland, Ohio
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131
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Schweitzer VA, van Heijl I, van Werkhoven CH, Islam J, Hendriks-Spoor KD, Bielicki J, Bonten MJM, Walker AS, Llewelyn MJ. The quality of studies evaluating antimicrobial stewardship interventions: a systematic review. Clin Microbiol Infect 2018; 25:555-561. [PMID: 30472426 DOI: 10.1016/j.cmi.2018.11.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 10/25/2018] [Accepted: 11/03/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Antimicrobial stewardship aims to optimize antibiotic use and minimize selection of antimicrobial resistance. The methodological quality of published studies in this field is unknown. AIMS Our objective was to perform a comprehensive systematic review of antimicrobial stewardship research design and identify features which limit validity and translation of research findings into clinical practice. SOURCES The following online database was searched: PubMed. STUDY ELIGIBILITY CRITERIA Studies published between January 1950 and January 2017, evaluating any antimicrobial stewardship intervention in the community or hospital setting, without restriction on study design or outcome. CONTENT We extracted data on pre-specified design quality features and factors that may influence design choices including (1) clinical setting, (2) age group studied, (3) when the study was conducted, (4) geographical region, and (5) financial support received. The initial search yielded 17 382 articles; 1008 were selected for full-text screening, of which 825 were included. Most studies (675/825, 82%) were non-experimental; 104 (15%) used interrupted time series analysis, 41 (6%) used external controls, and 19 (3%) used both. Studies in the community setting fulfilled a median of five out of 10 quality features (IQR 3-7) and 3 (IQR 2-4) in the hospital setting. Community setting studies (25%, 205/825) were significantly more likely to use randomization (OR 5.9; 95% CI 3.8-9.2), external controls (OR 5.6; 95% CI 3.6-8.5), and multiple centres (OR 10.5; 95% CI 7.1-15.7). From all studies, only 48% (398/825) reported clinical and 23% (190/825) reported microbiological outcomes. Quality did not improve over time. IMPLICATIONS Overall quality of antimicrobial stewardship studies is low and has not improved over time. Most studies do not report clinical and microbiological outcome data. Studies conducted in the community setting were associated with better quality. These limitations should inform the design of future stewardship evaluations so that a robust evidence base can be built to guide clinical practice.
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Affiliation(s)
- V A Schweitzer
- Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, The Netherlands.
| | - I van Heijl
- Department of Clinical Pharmacy and Medical Microbiology, Tergooi Hospital, Hilversum/Blaricum, The Netherlands
| | - C H van Werkhoven
- Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, The Netherlands
| | - J Islam
- Department of Global Health and Infection, Brighton and Sussex Medical School, Falmer, UK
| | - K D Hendriks-Spoor
- Department of Clinical Pharmacy and Medical Microbiology, Tergooi Hospital, Hilversum/Blaricum, The Netherlands
| | - J Bielicki
- Paediatric Infectious Disease Research Group, St George's University of London, London, UK
| | - M J M Bonten
- Department of Medical Microbiology, University Medical Center Utrecht, The Netherlands
| | - A S Walker
- MRC Clinical Trials Unit, University College London, London, UK
| | - M J Llewelyn
- Department of Global Health and Infection, Brighton and Sussex Medical School, Falmer, UK
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Poole NM. Judicious antibiotic prescribing in ambulatory pediatrics: Communication is key. Curr Probl Pediatr Adolesc Health Care 2018; 48:306-317. [PMID: 30389361 DOI: 10.1016/j.cppeds.2018.09.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Children in outpatient clinics are prescribed over 15 million courses of unnecessary antibiotics annually. Clinicians have identified parent pressure for antibiotics, parent satisfaction, and time constraints as the primary drivers of unnecessary antibiotic prescribing. Over the past decade, parents have become more aware that antibiotics only treat bacterial infections, yet continue to report an expectation for antibiotics in 50-65% of acute care visits. Parental expectations for antibiotics stem from parental concerns about symptom severity and a desire to alleviate symptoms. Clinicians can address parental concerns when they assess the severity of illness through a physical exam, provide a clear explanation for the symptoms, recommend ways to alleviate the symptoms, and provide council on when to be concerned. When clinicians fail to address parental concerns, parents are more likely to challenge the diagnosis or treatment recommendations, clinicians are more likely to perceive that parent as expecting an antibiotic, and antibiotics are significantly more likely to be prescribed. Parents that expect antibiotics are more likely to communicate using a 'candidate diagnosis' (e.g., "Johnny has strep throat.") and resist the diagnosis or treatment given. Clinicians can recognize these parental communication patterns and use specific communication practices shown to decrease unnecessary antibiotic prescribing. When parents expect antibiotics, clinicians should (1) review physical exam findings using 'no problem' commentary (e.g., "This ear is just a little red."), (2) deliver a specific diagnosis (e.g., avoid 'a virus'), (3) use a two-part negative/positive treatment recommendation (e.g., "On the one hand, antibiotics will not help. On the other hand, ibuprofen can help with pain."), and (4) provide a contingency plan. Clinicians should feel comfortable discussing the risks and benefits of antibiotics. Effective communication between parents and clinicians in outpatient clinics leads to more judicious antibiotic prescribing, higher parent satisfaction scores, and more efficient clinic visits.
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Affiliation(s)
- Nicole M Poole
- Seattle Children's Research Institute, Seattle, WA, United States; University of Washington, Seattle, WA, United States; Seattle Children's Hospital, Seattle, WA, United States.
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133
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From paper to practice: Strategies for improving antibiotic stewardship in the pediatric ambulatory setting. Curr Probl Pediatr Adolesc Health Care 2018; 48:289-305. [PMID: 30322711 DOI: 10.1016/j.cppeds.2018.09.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Antibiotic stewardship aims to better patient outcomes, reduce antibiotic resistance, and decrease unnecessary health care costs by improving appropriate antibiotic use. More than half of annual antibiotic expenditures for antibiotics in the United States are prescribed in the ambulatory setting. This review provides a summary of evidence based strategies shown to improve antibiotic prescribing in ambulatory care settings including: providing education to patients and their families, providing education to clinicians regarding best practices for specific conditions, providing communications training to clinicians, implementing disease-specific treatment algorithms, implementing delayed prescribing for acute otitis media, supplying prescribing feedback to providers with peer comparisons, using commitment letters, and prompting providers to justify antibiotic prescribing for diagnoses for which antibiotics are not typically recommended. These various mechanisms to improve stewardship can be tailored to a specific practice's work flow and culture. Interventions should be used in combination to maximize impact. The intent with this review is to provide an overview of strategies that pediatric providers can take from paper to practice.
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Schwartz KL, Achonu C, Brown KA, Langford B, Daneman N, Johnstone J, Garber G. Regional variability in outpatient antibiotic use in Ontario, Canada: a retrospective cross-sectional study. CMAJ Open 2018; 6:E445-E452. [PMID: 30381321 PMCID: PMC6208056 DOI: 10.9778/cmajo.20180017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Regional variability in antibiotic use is associated with both antibiotic overuse and antimicrobial resistance. Our objectives were to benchmark outpatient antibiotic use and to evaluate geographic variability among health regions in the province of Ontario, Canada. METHODS This was a cross-sectional study of antibiotics dispensed from outpatient retail pharmacies in Ontario between March 2016 and February 2017. We analyzed variability in the number of antibiotic prescriptions dispensed per 1000 population among Ontario's 14 health regions with crude and adjusted Poisson regression models. Adjusted models controlled for rurality, 4 physician characteristics and 6 population characteristics. RESULTS There were 8 352 578 antibiotics dispensed during the 1-year study period or 621 per 1000 population. The most commonly prescribed antibiotic classes were narrow-spectrum penicillins, macrolides, first-generation cephalosporins and second-generation fluoroquinolones, with adult women receiving the highest rate of prescriptions: 985 antibiotic prescriptions per 1000 population. There was geographic variability in total and class-specific antibiotic use. In the health region with the highest use 778 antibiotics were dispensed per 1000 population whereas in the health region with the lowest use 534 antibiotics were dispensed per 1000 population. The adjusted marginal standardized antibiotic prescription rates for the health regions with the highest and lowest use were 787 (95% confidence interval [CI] 658-934) and 546 (95% CI 494-606) antibiotic prescriptions per 1000 population, respectively. INTERPRETATION We described baseline antibiotic usage in Ontario over a 12-month period, noting variability among some health regions. Our findings highlight the need for interventions to optimize antibiotic use and slow the emergence of antimicrobial resistance.
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Affiliation(s)
- Kevin L Schwartz
- Public Health Ontario (Schwartz, Achonu, Brown, Langford, Daneman, Johnstone, Garber); Dalla Lana School of Public Health (Schwartz, Brown, Johnstone); Sunnybrook Health Sciences Centre (Daneman); Department of Medicine (Daneman, Garber), University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Garber), Ottawa, Ont.
| | - Camille Achonu
- Public Health Ontario (Schwartz, Achonu, Brown, Langford, Daneman, Johnstone, Garber); Dalla Lana School of Public Health (Schwartz, Brown, Johnstone); Sunnybrook Health Sciences Centre (Daneman); Department of Medicine (Daneman, Garber), University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Garber), Ottawa, Ont
| | - Kevin Antoine Brown
- Public Health Ontario (Schwartz, Achonu, Brown, Langford, Daneman, Johnstone, Garber); Dalla Lana School of Public Health (Schwartz, Brown, Johnstone); Sunnybrook Health Sciences Centre (Daneman); Department of Medicine (Daneman, Garber), University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Garber), Ottawa, Ont
| | - Bradley Langford
- Public Health Ontario (Schwartz, Achonu, Brown, Langford, Daneman, Johnstone, Garber); Dalla Lana School of Public Health (Schwartz, Brown, Johnstone); Sunnybrook Health Sciences Centre (Daneman); Department of Medicine (Daneman, Garber), University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Garber), Ottawa, Ont
| | - Nick Daneman
- Public Health Ontario (Schwartz, Achonu, Brown, Langford, Daneman, Johnstone, Garber); Dalla Lana School of Public Health (Schwartz, Brown, Johnstone); Sunnybrook Health Sciences Centre (Daneman); Department of Medicine (Daneman, Garber), University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Garber), Ottawa, Ont
| | - Jennie Johnstone
- Public Health Ontario (Schwartz, Achonu, Brown, Langford, Daneman, Johnstone, Garber); Dalla Lana School of Public Health (Schwartz, Brown, Johnstone); Sunnybrook Health Sciences Centre (Daneman); Department of Medicine (Daneman, Garber), University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Garber), Ottawa, Ont
| | - Gary Garber
- Public Health Ontario (Schwartz, Achonu, Brown, Langford, Daneman, Johnstone, Garber); Dalla Lana School of Public Health (Schwartz, Brown, Johnstone); Sunnybrook Health Sciences Centre (Daneman); Department of Medicine (Daneman, Garber), University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Garber), Ottawa, Ont
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Community pharmacy interventions to improve antibiotic stewardship and implications for pharmacy education: A narrative overview. Res Social Adm Pharm 2018; 15:627-631. [PMID: 30279131 DOI: 10.1016/j.sapharm.2018.09.017] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 09/25/2018] [Accepted: 09/25/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND Antibiotic resistance is one of the world's most pressing public health problems, resulting in over 23,000 deaths per year. One of the main contributing factors to antimicrobial resistance is antibiotic misuse and overuse. Community pharmacists can play a role in reducing antibiotic resistance, since they are one of the most accessible healthcare professionals. OBJECTIVE The purpose of this paper is to describe community pharmacy interventions and strategies to reduce antibiotic misuse and overuse and to discuss the implications for pharmacy training. METHODS A narrative overview strategy was employed to identify papers on antibiotic stewardship and the role of the community pharmacist. Our review examined potential stewardship strategies and interventions within community pharmacy practice that provide opportunities for pharmacists to engage or lead in the reduction of antimicrobial resistance. RESULTS We describe five promising community pharmacist-led intervention strategies: Collaborative Practice Agreements (CPAs), point-of-care (POC) testing, patient consultations, academic detailing and serving as an advocate for patients and other healthcare providers CONCLUSIONS: This review highlights topics that may warrant increased attention in pharmacy school curricula. Pharmacy schools may want to consider modifying their curricula to address the shifts in practice of the community pharmacist - emphasizing the expanded role of the pharmacist in patient care and public health issues such as outpatient antibiotic stewardship.
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Durkin MJ, Keller M, Butler AM, Kwon JH, Dubberke ER, Miller AC, Polgreen PM, Olsen MA. An Assessment of Inappropriate Antibiotic Use and Guideline Adherence for Uncomplicated Urinary Tract Infections. Open Forum Infect Dis 2018; 5:ofy198. [PMID: 30191156 PMCID: PMC6121225 DOI: 10.1093/ofid/ofy198] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 08/08/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND In 2011, The Infectious Diseases Society of America released a clinical practice guideline (CPG) that recommended short-course antibiotic therapy and avoidance of fluoroquinolones for uncomplicated urinary tract infections (UTIs). Recommendations from this CPG were rapidly disseminated to clinicians via review articles, UpToDate, and the Centers for Disease Control and Prevention website; however, it is unclear if this CPG had an impact on national antibiotic prescribing practices. METHODS We performed a retrospective cohort study of outpatient and emergency department visits within a commercial insurance database between January 1, 2009, and December 31, 2013. We included nonpregnant women aged 18-44 years who had an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code for a UTI with a concurrent antibiotic prescription. We performed interrupted time series analyses to determine the impact of the CPG on the appropriateness of the antibiotic agent and duration. RESULTS We identified 654 432 women diagnosed with UTI. The patient population was young (mean age, 31 years) and had few comorbidities. Fluoroquinolones, nonfirstline agents, were the most commonly prescribed antibiotic class both before and after release of the guidelines (45% vs 42%). Wide variation was observed in the duration of treatment, with >75% of prescriptions written for nonrecommended treatment durations. The CPG had minimal impact on antibiotic prescribing behavior by providers. CONCLUSIONS Inappropriate antibiotic prescribing is common for the treatment of UTIs. The CPG was not associated with a clinically meaningful change in national antibiotic prescribing practices for UTIs. Further interventions are necessary to improve outpatient antibiotic prescribing for UTIs.
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Affiliation(s)
- Michael J Durkin
- Division of Infectious Diseases, Department of Internal Medicine
| | - Matthew Keller
- Division of Infectious Diseases, Department of Internal Medicine
| | - Anne M Butler
- Division of Infectious Diseases, Department of Internal Medicine
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Jennie H Kwon
- Division of Infectious Diseases, Department of Internal Medicine
| | - Erik R Dubberke
- Division of Infectious Diseases, Department of Internal Medicine
| | | | - Phillip M Polgreen
- Department of Epidemiology, College of Public Health
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa
| | - Margaret A Olsen
- Division of Infectious Diseases, Department of Internal Medicine
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis, St. Louis, Missouri
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Manne M, Deshpande A, Hu B, Patel A, Taksler GB, Misra-Hebert AD, Jolly SE, Brateanu A, Bales RW, Rothberg MB. Provider Variation in Antibiotic Prescribing and Outcomes of Respiratory Tract Infections. South Med J 2018; 111:235-242. [PMID: 29719037 DOI: 10.14423/smj.0000000000000795] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Inappropriate antibiotic use for respiratory tract infection (RTI) is an ongoing problem linked to the emergence of drug resistance and other adverse effects. Less is known about the prescribing practices of individual physicians or the impact of physician prescribing habits on patient outcomes. We studied the prescribing practices of providers for acute RTIs in an integrated health system, identified patient factors associated with receipt of an antibiotic and assessed the relation between providers' adjusted prescribing rates and a number of patient outcomes. METHODS This was a retrospective analysis of adults with an RTI visit to any primary care providers across the Cleveland Clinic Health System in 2011-2012. Patients with a history of chronic obstructive pulmonary disease or immunocompromised status were excluded. Logistic regression was used to examine patient factors associated with receipt of an antibiotic. RESULTS Of 31,416 patients with an RTI, 54.8% received an antibiotic. Patient factors associated with antibiotic prescribing included white race (odds ratio [OR] 1.35, P < 0.001), presence of fever (OR 1.66, P < 0.001), and a diagnosis of bronchitis (OR 10.98, P < 0.001) or sinusitis (OR 33.85, P < 0.001). Among 290 providers with ≥10 RTI visits, adjusted antibiotic prescribing rates ranged from 0% to 100% (mean 49%). Antibiotics were prescribed more often for sinusitis (OR 33.85, P < 0.001), bronchitis (OR 10.98, P < 0.001), or pharyngitis (OR 1.76, P < 0.001) compared with upper respiratory tract infection. Patients who were prescribed antibiotics at the index visit were more likely to return for RTI within 1 year (adjusted OR 1.26, P < 0.001). Emergency department visits for respiratory complications were rare and not associated with antibiotic receipt. CONCLUSIONS Antibiotic prescribing for RTI varies widely among physicians and cannot be explained by patient factors. Patients prescribed antibiotics for RTI were more likely to return for RTI.
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Affiliation(s)
- Mahesh Manne
- From the Department of Internal Medicine, Medicine Institute, Cleveland Clinic, and the Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Abhishek Deshpande
- From the Department of Internal Medicine, Medicine Institute, Cleveland Clinic, and the Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Bo Hu
- From the Department of Internal Medicine, Medicine Institute, Cleveland Clinic, and the Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Aditi Patel
- From the Department of Internal Medicine, Medicine Institute, Cleveland Clinic, and the Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Glen B Taksler
- From the Department of Internal Medicine, Medicine Institute, Cleveland Clinic, and the Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Anita D Misra-Hebert
- From the Department of Internal Medicine, Medicine Institute, Cleveland Clinic, and the Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Stacey E Jolly
- From the Department of Internal Medicine, Medicine Institute, Cleveland Clinic, and the Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Andrei Brateanu
- From the Department of Internal Medicine, Medicine Institute, Cleveland Clinic, and the Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Robert W Bales
- From the Department of Internal Medicine, Medicine Institute, Cleveland Clinic, and the Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Michael B Rothberg
- From the Department of Internal Medicine, Medicine Institute, Cleveland Clinic, and the Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
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Mora Pinzon MC, Buie R, Liou JI, Shirley DK, Evans CT, Ramanathan S, Poggensee L, Safdar N. Outcomes of Community and Healthcare-onsetClostridium difficileInfections. Clin Infect Dis 2018; 68:1343-1350. [DOI: 10.1093/cid/ciy715] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 08/17/2018] [Indexed: 12/14/2022] Open
Affiliation(s)
| | - Ronald Buie
- Department of Biomedical Informatics and Medical Education, University of Washington School of Medicine, Seattle
- William S. Middleton Memorial Veterans Affairs Hospital, Madison
| | - Jinn-ing Liou
- William S. Middleton Memorial Veterans Affairs Hospital, Madison
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison
| | - Daniel K Shirley
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison
| | - Charlesnika T Evans
- Center of Innovation for Complex Chronic Healthcare, Department of Veterans Affairs, Edward Hines Jr Veterans Affairs Hospital, Chicago, Illinois
- Department of Preventive Medicine and Center for Healthcare Studies, Northwestern University, Chicago, Illinois
| | - Swetha Ramanathan
- Center of Innovation for Complex Chronic Healthcare, Department of Veterans Affairs, Edward Hines Jr Veterans Affairs Hospital, Chicago, Illinois
| | - Linda Poggensee
- Center of Innovation for Complex Chronic Healthcare, Department of Veterans Affairs, Edward Hines Jr Veterans Affairs Hospital, Chicago, Illinois
| | - Nasia Safdar
- William S. Middleton Memorial Veterans Affairs Hospital, Madison
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison
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139
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Kim YA, Park YS, Youk T, Lee H, Lee K. Changes in Antimicrobial Usage Patterns in Korea: 12-Year Analysis Based on Database of the National Health Insurance Service-National Sample Cohort. Sci Rep 2018; 8:12210. [PMID: 30111796 PMCID: PMC6093866 DOI: 10.1038/s41598-018-30673-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 08/02/2018] [Indexed: 01/24/2023] Open
Abstract
National antimicrobial usage and prescription patterns during the 12 years from 2002 to 2013 were analyzed using the National Health Insurance Service-National Sample Cohort. Antimicrobial usage was analyzed by major illness, sex, age, area of residence, income rank, diagnosis, and type of medical institution for each year. Total antimicrobial prescriptions increased from 15.943 daily defined dose (DDD)/1,000 inhabitants/day in 2002 to 24.219 in 2013. In 2013, 72% of total prescriptions were administered in clinics. Antimicrobials were most frequently prescribed to children younger than 10 years, followed by adults aged 70 years or older and those aged 60-69 years. Penicillins and cephems were the most popular classes of antimicrobial used. In 2013, 48% of total antibiotic usage (11.683 DDD/1,000 inhabitants/day) was due to respiratory diseases. After the Korean government has implemented a series of healthcare policies, antibiotic prescription decreased for the treatment of upper respiratory infection, the causative agents are mostly viruses.
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Affiliation(s)
- Young Ah Kim
- Department of Laboratory Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Yoon Soo Park
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea.
| | - Taemi Youk
- Research Institute, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Hyukmin Lee
- Department of Laboratory Medicine and Research Institute of Bacterial Resistance, Yonsei University College of Medicine, Seoul, Korea
| | - Kyungwon Lee
- Department of Laboratory Medicine and Research Institute of Bacterial Resistance, Yonsei University College of Medicine, Seoul, Korea
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Blanchette L, Gauthier T, Heil E, Klepser M, Kelly KM, Nailor M, Wei W, Suda K. The essential role of pharmacists in antibiotic stewardship in outpatient care: An official position statement of the Society of Infectious Diseases Pharmacists. J Am Pharm Assoc (2003) 2018; 58:481-484. [PMID: 30007508 DOI: 10.1016/j.japh.2018.05.013] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 05/15/2018] [Accepted: 05/29/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The objective of this position statement is to describe the essential role of pharmacists in antimicrobial stewardship in outpatient care. DATA SOURCES N/A. SUMMARY The majority of antibiotic prescribing occurs in outpatient care settings highlighting the need for antibiotic stewardship in the community. Given their expertise on medication management, pharmacists are essential to any antibiotic stewardship effort. CONCLUSION As the regulations for antibiotic stewardship in outpatient settings continue to evolve and optimal stewardship strategies are defined, pharmacists must be leaders in the implementation of these programs.
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Emberger J, Tassone D, Stevens MP, Markley JD. The Current State of Antimicrobial Stewardship: Challenges, Successes, and Future Directions. Curr Infect Dis Rep 2018; 20:31. [PMID: 29959545 DOI: 10.1007/s11908-018-0637-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW The aim of this study is to examine the current state of the field of antimicrobial stewardship (AS) by highlighting key challenges and successes, as well as exciting future directions. RECENT FINDINGS AS mandates from the Centers for Medicare and Medicaid (CMS) and the Joint Commission (TJC) will stimulate increased compliance with current AS standards, but overall compliance is currently poor. Key challenges to progress in the field of AS include insufficient workforce and monetary resources, poorly defined AS metrics, and much needed expansion beyond the inpatient hospital setting. Despite these challenges, massive progress has been made in the last two and a half decades since the field of AS emerged. AS metrics are rapidly evolving and transforming the way antimicrobial stewardship programs (ASPs) measure success. Rapid diagnostics and diagnostic test stewardship are proving to be extremely effective when coupled with an ASP. Telehealth may improve access to ASP expertise in resource poor settings, and the role of bedside nurses as ASP team members has the potential to greatly augment ASP efforts. Allergy testing as an ASP strategy remains largely underutilized. ASPs have made significant gains in the battle against antimicrobial resistance (AR), but considerable advancement is still needed. Awareness of current challenges is critical to ensure progress in the field. The field of AS is expanding and transforming rapidly through integration, technology, and improved processes.
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Affiliation(s)
- Jennifer Emberger
- Virginia Commonwealth University Medical Center, VMI Building, 2nd Floor, Room 204, Richmond, VA, 23298, USA.
| | - Dan Tassone
- Hunter Holmes McGuire Veterans Affairs Medical Center, Virginia Commonwealth University School of Pharmacy, Richmond, VA, USA
| | - Michael P Stevens
- Department of Internal Medicine, Division of Infectious Diseases, Virginia Commonwealth University Medical Center, Richmond, VA, USA
| | - J Daniel Markley
- Department of Internal Medicine, Division of Infectious Diseases, Hunter Holmes McGuire Veterans Affairs Medical Center, Virginia Commonwealth University Medical Center, Richmond, VA, USA
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Yates TD, Davis ME, Taylor YJ, Davidson L, Connor CD, Buehler K, Spencer MD. Not a magic pill: a qualitative exploration of provider perspectives on antibiotic prescribing in the outpatient setting. BMC FAMILY PRACTICE 2018; 19:96. [PMID: 29933762 PMCID: PMC6015451 DOI: 10.1186/s12875-018-0788-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 05/31/2018] [Indexed: 01/21/2023]
Abstract
BACKGROUND Inappropriate prescribing of antibiotics poses an urgent public health threat. Limited research has examined factors associated with antibiotic prescribing practices in outpatient settings. The goals of this study were to explore elements influencing provider decisions to prescribe antibiotics, identify provider recommendations for interventions to reduce inappropriate antibiotic use, and inform the clinical management of patients in the outpatient environment for infections that do not require antibiotics. METHODS This was a qualitative study using semi-structured interviews with key informants. Seventeen outpatient providers (10 medical doctors and 7 advanced care practitioners) within a large healthcare system in Charlotte, North Carolina, participated. Interviews were audio recorded, transcribed, and analyzed for themes. RESULTS Primary barriers to reducing inappropriate antibiotic prescribing included patient education and expectations, system-level factors, and time constraints. Providers indicated they would be interested in having system-wide, evidence-based guidelines to inform their prescribing decisions and that they would also be receptive to efforts to improve their awareness of their own prescribing practices. Results further suggested that providers experience a high demand for antibiotic prescriptions; consequently, patient education around appropriate use would be beneficial. CONCLUSIONS Findings suggest that antibiotic prescribing in the outpatient setting is influenced by many pressures, including patient demand and patient satisfaction. Training on appropriate antibiotic prescribing, guideline-based decision support, feedback on prescribing practices, and patient education are recommended interventions to improve levels of appropriate prescribing.
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Affiliation(s)
- Traci D Yates
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, NC, USA.
| | - Marion E Davis
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, NC, USA
| | - Yhenneko J Taylor
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, NC, USA
| | - Lisa Davidson
- Division of Infectious Disease, Atrium Health, Charlotte, NC, USA
| | - Crystal D Connor
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, NC, USA
| | - Katherine Buehler
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, NC, USA
| | - Melanie D Spencer
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, NC, USA
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Lum EP, Page K, Whitty JA, Doust J, Graves N. Antibiotic prescribing in primary healthcare: Dominant factors and trade-offs in decision-making. Infect Dis Health 2018. [DOI: 10.1016/j.idh.2017.12.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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144
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Monnier AA, Eisenstein BI, Hulscher ME, Gyssens IC. Towards a global definition of responsible antibiotic use: results of an international multidisciplinary consensus procedure. J Antimicrob Chemother 2018; 73:vi3-vi16. [PMID: 29878216 PMCID: PMC5989615 DOI: 10.1093/jac/dky114] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background Conducted as part of the Driving Reinvestment in Research and Development and Responsible Antibiotic Use (DRIVE-AB) project, this study aimed to identify key elements for a global definition of responsible antibiotic use based on diverse stakeholder input. Methods A three-step RAND-modified Delphi method was applied. First, a systematic review of antibiotic stewardship literature and relevant organization web sites identified definitions and synonyms of responsible use. Identified elements of definitions were presented by questionnaire to a multidisciplinary international stakeholder panel for appraisal of their relevance. Finally, questionnaire results were discussed in a consensus meeting. Results The systematic review and the web site search identified 17 synonyms (e.g. appropriate, correct) and 22 potential elements to include in a definition of responsible use. Elements were grouped into patient-level (e.g. Indication, Documentation) or societal-level elements (e.g. Education, Future Effectiveness). Forty-eight stakeholders with diverse backgrounds [medical community, public health, patients, antibiotic research and development (R&D), regulators, governments] from 18 countries across all continents participated in the questionnaire. Based on relevance scores, 21 elements were retained, 9 were rephrased and 1 was added. Together, the 22 elements and associated best-practice descriptions comprise an exhaustive list of elements to be considered when defining responsible use. Conclusions Combination of concepts from the literature and stakeholder opinion led to an international multidisciplinary consensus on a global definition of responsible antibiotic use. The widely diverging perspectives of stakeholders providing input should ensure the comprehensiveness and relevance of the definition for both individual patients and society. An aspirational goal would be to address all elements.
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Affiliation(s)
- Annelie A Monnier
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Scientific Center for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- Faculty of Medicine, Research Group of Immunology and Biochemistry, Hasselt University, Hasselt, Belgium
| | | | - Marlies E Hulscher
- Scientific Center for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Inge C Gyssens
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Faculty of Medicine, Research Group of Immunology and Biochemistry, Hasselt University, Hasselt, Belgium
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Piltcher OB, Kosugi EM, Sakano E, Mion O, Testa JRG, Romano FR, Santos MCJ, Di Francesco RC, Mitre EI, Bezerra TFP, Roithmann R, Padua FG, Valera FCP, Lubianca Neto JF, Sá LCB, Pignatari SSN, Avelino MAG, Caixeta JADS, Anselmo-Lima WT, Tamashiro E. How to avoid the inappropriate use of antibiotics in upper respiratory tract infections? A position statement from an expert panel. Braz J Otorhinolaryngol 2018; 84:265-279. [PMID: 29588108 PMCID: PMC9449220 DOI: 10.1016/j.bjorl.2018.02.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 02/01/2018] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Bacterial resistance burden has increased in the past years, mainly due to inappropriate antibiotic use. Recently it has become an urgent public health concern due to its impact on the prolongation of hospitalization, an increase of total cost of treatment and mortality associated with infectious disease. Almost half of the antimicrobial prescriptions in outpatient care visits are prescribed for acute upper respiratory infections, especially rhinosinusitis, otitis media, and pharyngotonsillitis. In this context, otorhinolaryngologists play an important role in orienting patients and non-specialists in the utilization of antibiotics rationally and properly in these infections. OBJECTIVES To review the most recent recommendations and guidelines for the use of antibiotics in acute otitis media, acute rhinosinusitis, and pharyngotonsillitis, adapted to our national reality. METHODS A literature review on PubMed database including the medical management in acute otitis media, acute rhinosinusitis, and pharyngotonsillitis, followed by a discussion with a panel of specialists. RESULTS Antibiotics must be judiciously prescribed in uncomplicated acute upper respiratory tract infections. The severity of clinical presentation and the potential risks for evolution to suppurative and non-suppurative complications must be taken into 'consideration'. CONCLUSIONS Periodic revisions on guidelines and recommendations for treatment of the main acute infections are necessary to orient rationale and appropriate use of antibiotics. Continuous medical education and changes in physicians' and patients' behavior are required to modify the paradigm that all upper respiratory infection needs antibiotic therapy, minimizing the consequences of its inadequate and inappropriate use.
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Affiliation(s)
- Otávio Bejzman Piltcher
- Universidade Federal do Rio Grande do Sul (UFRGS), Faculdade de Medicina (FAMED), Departamento de Oftalmologia e Otorrinolaringologia, Porto Alegre, RS, Brazil
| | - Eduardo Macoto Kosugi
- Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM), Departamento de Otorrinolaringologia e Cirurgia de Cabeça e Pescoço, São Paulo, SP, Brazil
| | - Eulalia Sakano
- Universidade Estadual de Campinas (UNICAMP), Departamento de Otorrinolaringologia e Oftalmologia, Campinas, SP, Brazil
| | - Olavo Mion
- Universidade de São Paulo (USP), Faculdade de Medicina (FM), Disciplina de Otorrinolaringologia, São Paulo, SP, Brazil
| | - José Ricardo Gurgel Testa
- Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM), Departamento de Otorrinolaringologia e Cirurgia de Cabeça e Pescoço, São Paulo, SP, Brazil
| | - Fabrizio Ricci Romano
- Universidade de São Paulo (USP), Faculdade de Medicina (FM), Otorrinolaringologia, São Paulo, SP, Brazil; Hospital Infantil Sabará, Otorrinolaringologia, São Paulo, SP, Brazil
| | - Marco Cesar Jorge Santos
- Hospital Paranaense de Otorrinolaringologia (IPO), Instituto Paranaense de Otorrinolaringologia, Curitiba, PR, Brazil
| | - Renata Cantisani Di Francesco
- Universidade de São Paulo (USP), Faculdade de Medicina (FM), Disciplina de Otorrinolaringologia, São Paulo, SP, Brazil
| | - Edson Ibrahim Mitre
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, SP, Brazil
| | - Thiago Freire Pinto Bezerra
- Universidade Federal de Pernambuco (UFPE), Departamento de Cirurgia, Divisão de Otorrinolaringologia, Recife, PE, Brazil
| | - Renato Roithmann
- Universidade Luterana do Brasil, Faculdade de Medicina, Porto Alegre, RS, Brazil
| | - Francini Greco Padua
- Universidade de São Paulo (USP), Faculdade de Medicina (FM), São Paulo, SP, Brazil; Hospital Albert Einstein, São Paulo, SP, Brazil
| | - Fabiana Cardoso Pereira Valera
- Universidade de São Paulo (USP), Faculdade de Medicina de Ribeirão Preto (FMRP), Departamento de Oftalmologia, Otorrinolaringologia e Cirurgia de Cabeça e Pescoço, Ribeirão Preto, SP, Brazil
| | - José Faibes Lubianca Neto
- Universidade Federal de Ciências da Saúde de Porto Alegre, Hospital da Criança Santo Antônio, Serviço de Otorrinolaringologia Pediátrica, Porto Alegre, RS, Brazil
| | - Leonardo Conrado Barbosa Sá
- Universidade do Estado do Rio de Janeiro (UERJ), Faculdade de Ciências Médicas, Disciplina de Otorrinolaringologia, Rio de Janeiro, RJ, Brazil
| | - Shirley Shizue Nagata Pignatari
- Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM), Departamento de Otorrinolaringologia e Cirurgia de Cabeça e Pescoço, São Paulo, SP, Brazil
| | - Melissa Ameloti Gomes Avelino
- Universidade Federal de Goiás (UFG), Goiânia, GO, Brazil; Pontifícia Universidade Católica de Goiás (PUC-GO), Goiânia, GO, Brazil
| | | | - Wilma Terezinha Anselmo-Lima
- Universidade de São Paulo (USP), Faculdade de Medicina de Ribeirão Preto (FMRP), Departamento de Oftalmologia, Otorrinolaringologia e Cirurgia de Cabeça e Pescoço, Ribeirão Preto, SP, Brazil
| | - Edwin Tamashiro
- Universidade de São Paulo (USP), Faculdade de Medicina de Ribeirão Preto (FMRP), Departamento de Oftalmologia, Otorrinolaringologia e Cirurgia de Cabeça e Pescoço, Ribeirão Preto, SP, Brazil.
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Köchling A, Löffler C, Reinsch S, Hornung A, Böhmer F, Altiner A, Chenot JF. Reduction of antibiotic prescriptions for acute respiratory tract infections in primary care: a systematic review. Implement Sci 2018; 13:47. [PMID: 29554972 PMCID: PMC5859410 DOI: 10.1186/s13012-018-0732-y] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 02/27/2018] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Although most respiratory tract infections (RTIs) are due to viral infections, they cause the majority of antibiotic (Abx) prescriptions in primary care. This systematic review summarises the evidence on the effectiveness of interventions in primary care aiming to reduce Abx prescriptions in patients ≥ 13 years for acute RTI. METHODS We searched the databases "MEDLINE/PubMed" and "Cochrane Library" for the period from January 1, 2005, to August 31, 2016, for randomised controlled trials (RCTs) in primary care aiming at the reduction of Abx prescriptions for patients suffering from RTI. Out of 690 search results, 67 publications were retrieved and 17 RCTs were included. We assumed an absolute change of 10% as minimal important change. RESULTS Twelve out of 17 included RCTs showed statistically significant lower Abx prescription rates in the intervention groups, but only six of them reported a clinically relevant reduction according to our definition. Communication skills training (CST) and point-of-care testing (POCT) were the most effective interventions. Pre-intervention Abx prescription rates varied between 13.5% and 80% and observed reductions ranged from 1.5 to 23.3%. Studies with post-intervention rates lower than 20% had no significant effects. Post-intervention observation periods ranged from 2 weeks up to 3.5 years. The design of the trials was heterogeneous precluding calculation of pooled effect size. The reporting of many RCTs was poor. CONCLUSIONS CST and POCT alone or as adjunct can reduce antibiotic prescriptions for RTI. Eleven out of 17 trials were not successfully reducing Abx prescription rates according to our definition of minimal important change. However, five of them reported a statistically significant reduction. Trials with initially lower prescription rates were less likely to be successful. Future trials should investigate sustainability of intervention effects for a longer time period. The generalisability of findings was limited due to heterogeneous designs and outcome measures. Therefore, a consensus of designing and reporting of studies aiming at reducing antibiotic prescriptions is urgently needed to generate meaningful evidence.
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Affiliation(s)
- Anna Köchling
- Clinic for Psychosomatic Medicine and Psychotherapy, University Medical Center, Rostock, Germany
- Institute of General Practice, University Medical Center, Rostock, Germany
| | - Christin Löffler
- Institute of General Practice, University Medical Center, Rostock, Germany
| | - Stefan Reinsch
- Department of Pediatric Pneumology, Immunology & Intensive Care Medicine Charité, University Medical Center Berlin, Berlin, Germany
| | - Anne Hornung
- Institute for Biostatistics and Informatics in Medicine and Ageing Research, University Medical Center Rostock, Rostock, Germany
| | - Femke Böhmer
- Institute of General Practice, University Medical Center, Rostock, Germany
| | - Attila Altiner
- Institute of General Practice, University Medical Center, Rostock, Germany
| | - Jean-François Chenot
- Institute for Community Medicine—Department of Family Medicine, University Greifswald, Greifswald, Germany
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147
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Holmes L, Struwe L, Waltman N. Evaluation of an Antibiotic Stewardship Program in a University Health Center. J Nurse Pract 2018. [DOI: 10.1016/j.nurpra.2017.11.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Physician Perceptions Regarding Antimicrobial Use in End-of-Life Care. Infect Control Hosp Epidemiol 2018; 39:383-390. [PMID: 29428002 DOI: 10.1017/ice.2018.6] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND The decision to utilize antimicrobials in end-of-life situations is complex. Understanding the reasons why physicians prescribe antimicrobials in this patient population is important for informing the design of antimicrobial stewardship interventions. METHODS A 51-item survey containing both closed and open-ended questions on end-of-life antimicrobial use was administered to physicians affiliated with the University of Pennsylvania and Children's Hospital of Philadelphia from January through April 2017. A mixed-methods approach was used to analyze responses. RESULTS Of 637 physicians surveyed, 283 responses (44.4%) were received. Most (86.2%) physicians believed that respecting a patient's wish to continue antimicrobials was important. Approximately half of physicians (49.8%) believed that antimicrobial use at the end of life contributes to resistance. A higher proportion of pediatricians would often or always continue antimicrobial treatment for active infections and for hospice patients whose death was imminent compared to adult physicians (P<.001). Analysis of free-text responses revealed additional reasons why physicians may continue antimicrobials at end of life, including meeting family expectations, wanting to avoid the perception of "giving up," uncertainty about prognosis, and reducing patient pain or discomfort. CONCLUSIONS Physician decision making concerning antimicrobial use in patients at the end of life is multifactorial. Clinicians may overweigh the benefits of antimicrobial therapy in end-of-life situations and view the importance of adhering to stewardship policies differently. Pediatric and adult clinicians have different approaches to this patient population. Better understanding of the complex decision making that occurs in the end-of-life patient population can help guide antimicrobial stewardship policies and improve patient care. Infect Control Hosp Epidemiol 2018;39:383-390.
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Tsutsui A, Yahara K, Shibayama K. Trends and patterns of national antimicrobial consumption in Japan from 2004 to 2016. J Infect Chemother 2018; 24:414-421. [PMID: 29428566 DOI: 10.1016/j.jiac.2018.01.003] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 12/18/2017] [Accepted: 01/09/2018] [Indexed: 12/19/2022]
Abstract
Frequent use of broad-spectrum antimicrobial classes has been reported in Japan; however, little is known about the long-term trend of national antimicrobial consumption, and that of individual agents. This study analyzed the national sales data of systemic antimicrobials from 2004 to 2016, derived from the IMS Japan Pharmaceutical Market database, to assess the consumption patterns of antimicrobial classes and agents in Japan. The number of defined daily doses per 1000 inhabitants per day (DID) was calculated for each antimicrobial agent. During the last 13 years, total antimicrobial consumption fluctuated by only 5% around the average of 14.41 DID. In 2016, the most used class was macrolides (32%), followed by cephalosporins (28%) and fluoroquinolones (19%). Oral agents comprised a large proportion (93%) of antimicrobial consumption. The most used agent, clarithromycin, accounted for 25% of all oral compounds used in 2016. The consumption of oral agents with high bioavailability, such as fluoroquinolones, amoxicillin, and sulfamethoxazole/trimethoprim increased, whereas that of cephalosporins decreased. In 2016, ceftriaxone was the most consumed parenteral agent, followed by cefazolin. The consumption of parenteral agents increased after 2009 when high-dose regimens of piperacillin/tazobactam, meropenem, and ampicillin/sulbactam were approved by the health insurance system. National antimicrobial consumption has been stable over the last 13 years. Moreover, shifts in the use of agents with high bioavailability and those approved for high-dose regimens were observed. However, the increased use of broad-spectrum agents is worrisome. A multifaceted approach is required to reduce overall antimicrobial consumption.
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Affiliation(s)
- Atsuko Tsutsui
- Antimicrobial Resistance Research Center, National Institute of Infectious Diseases, Higashimurayama, Tokyo 189-0002, Japan.
| | - Koji Yahara
- Antimicrobial Resistance Research Center, National Institute of Infectious Diseases, Higashimurayama, Tokyo 189-0002, Japan
| | - Keigo Shibayama
- Antimicrobial Resistance Research Center, National Institute of Infectious Diseases, Higashimurayama, Tokyo 189-0002, Japan
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Research Agenda for Antimicrobial Stewardship in the Veterans Health Administration. Infect Control Hosp Epidemiol 2018; 39:196-201. [PMID: 29417925 PMCID: PMC9793410 DOI: 10.1017/ice.2017.299] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Antimicrobial stewardship is vital to reducing the spread of antimicrobial resistance. A group of investigators and clinicians within the Veterans Health Administration set forth a research agenda for antimicrobial stewardship, including research targets for inpatient and outpatient stewardship activities, metrics, and antimicrobial dosing and duration.
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