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Aghlmandi S, Bielicki J, Bucher HC. 'Impact of the COVID-19 pandemic on antibiotic prescribing in high-prescribing primary care physicians in Switzerland' - Author's reply. Clin Microbiol Infect 2024; 30:967-968. [PMID: 38556211 DOI: 10.1016/j.cmi.2024.03.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 03/20/2024] [Accepted: 03/24/2024] [Indexed: 04/02/2024]
Affiliation(s)
- Soheila Aghlmandi
- Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland; Paediatric Research Center, University Children's Hospital Basel (UKBB), Basel, Switzerland.
| | - Julia Bielicki
- Infectious Diseases and Paediatric Research Centre University of Basel Children's Hospital and University of Basel, Basel, Switzerland; Centre for Neonatal and Paediatric Infection, St. George's University, London, UK
| | - Heiner C Bucher
- Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
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Schwartz KL, Shuldiner J, Langford BJ, Brown KA, Schultz SE, Leung V, Daneman N, Tadrous M, Witteman HO, Garber G, Grimshaw JM, Leis JA, Presseau J, Silverman MS, Taljaard M, Gomes T, Lacroix M, Brehaut J, Thavorn K, Gushue S, Friedman L, Zwarenstein M, Ivers N. Mailed feedback to primary care physicians on antibiotic prescribing for patients aged 65 years and older: pragmatic, factorial randomised controlled trial. BMJ 2024; 385:e079329. [PMID: 38839101 PMCID: PMC11151833 DOI: 10.1136/bmj-2024-079329] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/12/2024] [Indexed: 06/07/2024]
Abstract
OBJECTIVES To evaluate whether providing family physicians with feedback on their antibiotic prescribing compared with that of their peers reduces antibiotic prescriptions. To also identify effects on antibiotic prescribing from case-mix adjusted feedback reports and messages emphasising antibiotic associated harms. DESIGN Pragmatic, factorial randomised controlled trial. SETTING Primary care physicians in Ontario, Canada PARTICIPANTS: All primary care physicians were randomly assigned a group if they were eligible and actively prescribing antibiotics to patients 65 years or older. Physicians were excluded if had already volunteered to receive antibiotic prescribing feedback from another agency, or had opted out of the trial. INTERVENTION A letter was mailed in January 2022 to physicians with peer comparison antibiotic prescribing feedback compared with the control group who did not receive a letter (4:1 allocation). The intervention group was further randomised in a 2x2 factorial trial to evaluate case-mix adjusted versus unadjusted comparators, and emphasis, or not, on harms of antibiotics. MAIN OUTCOME MEASURES Antibiotic prescribing rate per 1000 patient visits for patients 65 years or older six months after intervention. Analysis was in the modified intention-to-treat population using Poisson regression. RESULTS 5046 physicians were included and analysed: 1005 in control group and 4041 in intervention group (1016 case-mix adjusted data and harms messaging, 1006 with case-mix adjusted data and no harms messaging, 1006 unadjusted data and harms messaging, and 1013 unadjusted data and no harms messaging). At six months, mean antibiotic prescribing rate was 59.4 (standard deviation 42.0) in the control group and 56.0 (39.2) in the intervention group (relative rate 0.95 (95% confidence interval 0.94 to 0.96). Unnecessary antibiotic prescribing (0.89 (0.86 to 0.92)), prolonged duration prescriptions defined as more than seven days (0.85 (0.83 to 0.87)), and broad spectrum prescribing (0.94 (0.92 to 0.95)) were also significantly lower in the intervention group compared with the control group. Results were consistent at 12 months post intervention. No significant effect was seen for including emphasis on harms messaging. A small increase in antibiotic prescribing with case-mix adjusted reports was noted (1.01 (1.00 to 1.03)). CONCLUSIONS Peer comparison audit and feedback letters significantly reduced overall antibiotic prescribing with no benefit of case-mix adjustment or harms messaging. Antibiotic prescribing audit and feedback is a scalable and effective intervention and should be a routine quality improvement initiative in primary care. TRIAL REGISTRATION ClinicalTrials.gov NCT04594200.
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Affiliation(s)
- Kevin L Schwartz
- Public Health Ontario, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, ON, Canada
| | - Jennifer Shuldiner
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Bradley J Langford
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Public Health Ontario, Toronto, ON, Canada
| | - Kevin A Brown
- Public Health Ontario, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | | | - Valerie Leung
- Public Health Ontario, Toronto, ON, Canada
- Michael Garron Hospital, Toronto East Health Network, Toronto, ON, Canada
| | - Nick Daneman
- Public Health Ontario, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Sunnybrook Research Institute, Toronto, ON, Canada
| | - Mina Tadrous
- ICES, Toronto, ON, Canada
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Holly O Witteman
- Department of Family and Emergency Medicine, Laval University, Quebec City, QC, Canada
- Vitam Research Centre for Sustainable Health, Quebec City, QC, Canada
| | - Gary Garber
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University of Ottawa, Ottawa, ON,
Canada
| | - Jeremy M Grimshaw
- Department of Medicine, University of Ottawa, Ottawa, ON,
Canada
- Clinical Epidemiology Program, Ottawa Hospital Research
Institute, Ottawa, ON, Canada
| | - Jerome A Leis
- Sunnybrook Research Institute, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Justin Presseau
- Clinical Epidemiology Program, Ottawa Hospital Research
Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa,
Ottawa, ON, Canada
| | | | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research
Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa,
Ottawa, ON, Canada
| | - Tara Gomes
- ICES, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Meagan Lacroix
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
| | - Jamie Brehaut
- Clinical Epidemiology Program, Ottawa Hospital Research
Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa,
Ottawa, ON, Canada
| | - Kednapa Thavorn
- ICES, Toronto, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research
Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa,
Ottawa, ON, Canada
| | | | | | - Merrick Zwarenstein
- Departments of Family Medicine and Epidemiology/Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Noah Ivers
- ICES, Toronto, ON, Canada
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
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Aghlmandi S, Halbeisen FS, Godet P, Signorell A, Sigrist S, Saccilotto R, Widmer AF, Zeller A, Bielicki J, Bucher HC. Impact of the COVID-19 pandemic on antibiotic prescribing in high-prescribing primary care physicians in Switzerland. Clin Microbiol Infect 2024; 30:353-359. [PMID: 38000535 DOI: 10.1016/j.cmi.2023.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 11/15/2023] [Accepted: 11/19/2023] [Indexed: 11/26/2023]
Abstract
OBJECTIVES The aim of this study was to evaluate antibiotic prescribing of medium-to-high prescribing primary care physicians being followed up after the completion of a Swiss national intervention trial of antibiotic prescription audit and feedback in the first SARS-CoV-2 pandemic year. METHODS We used health insurer based claims data to calculate monthly antibiotic prescription rates per 100 consultations (primary endpoint) and applying interrupted time series (ITS) analysis methods, we estimated the immediate (step change) and sustained effects (slope) of the SARS-CoV-2 epidemic in 2020 on antibiotic prescribing compared to the pre-pandemic trial period from 2017-2019. RESULTS We analysed data of 2945 of 3426 physicians (86.0%) from the trial with over 4 million consultations annually, who were in 2020 still in practice. Consultations dropped by 43% during the first pandemic year compared with 2017. Median monthly antibiotic prescription rates per 100 consultations in 2017 were 8.44 (Interquartile range [IQ] 6.32-11.50) and 8.35 (6.34-11.74) in the intervention and control groups, respectively, and increased to 15.63 (10.69-23.81) and 16.31 (10.65-24.72) per 100 consultations in 2020. ITS-derived incidence rate ratios for overall antibiotic prescriptions were 2.32 (95% CI 2.07-2.59) for the immediate pandemic effect, and 0.96 (0.95-0.98) for the sustained effect (change in slope in 2020 compared with 2017-2019). DISCUSSION The SARS-CoV-2 pandemic had a major impact on antibiotic prescription patterns in primary care in Switzerland. For future viral pandemics, intervention plans with timely activation steps to minimize unjustified antibiotic consumption in primary care should be prepared.
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Affiliation(s)
- Soheila Aghlmandi
- Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland; Paediatric Research Center, University Children's Hospital Basel (UKBB), Basel, Switzerland.
| | - Florian S Halbeisen
- Surgical Outcome Research Center, Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
| | | | | | | | - Ramon Saccilotto
- Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Andreas F Widmer
- Division of Infectious Diseases and Hospital Hygiene, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Andreas Zeller
- Centre for Primary Health Care, University of Basel, Basel, Switzerland
| | - Julia Bielicki
- Infectious Diseases and Paediatric Research Centre University of Basel Children's Hospital and University of Basel, Basel, Switzerland; Centre for Neonatal and Paediatric Infection, St. George's University, London, UK
| | - Heiner C Bucher
- Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
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Redel A, Feleszko W, Arcolaci A, Cefaloni F, Atanaskovic‐Markovic M, Braunstahl G, Boccabella C, Bonini M, Karavelia A, Louwers E, Mülleneisen N, O'Mahony L, Pini L, Rapiejko A, Shehu E, Sokolowska M, Untersmayr E, Tramper‐Stranders G. A survey study on antibiotic prescription practices for acute asthma exacerbations: An European academy of allergy and clinical immunology task force report. Clin Transl Allergy 2024; 14:e12345. [PMID: 38497844 PMCID: PMC10946284 DOI: 10.1002/clt2.12345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 02/15/2024] [Indexed: 03/19/2024] Open
Abstract
INTRODUCTION Guidelines recommend treating asthma exacerbations (AAEs) with bronchodilators combined with inhaled and/or systemic corticosteroids. Indications for antibiotic prescriptions for AAEs are usually not incorporated although the literature shows antibiotics are frequently prescribed. AIM To investigate the antibiotic prescription rates in AAEs and explore the possible determining factors of those practices. METHODS A digital survey was created to determine the antibiotic prescription rates in AAEs and the influencing factors for the prescription practices. The survey was distributed among European academy of allergy and clinical immunology (EAACI) members by mass emailing and through regional/national societies in the Netherlands, Italy, Greece, and Poland. Furthermore, we retrieved local antibiotic prescription rates. RESULTS In total, 252 participants completed the survey. Respondents stated that there is a lack of guidelines to prescribe antibiotics in AAEs. The median antibiotic prescription rate in this study was 19% [IQR: 0%-40%] and was significantly different between 4 professions: paediatrics 0% [IQR: 0%-37%], pulmonologists 25% [IQR: 10%-50%], general practitioners 25% [IQR: 0%-50%], and allergologists 17% [IQR: 0%-33%]) (p = 0.046). Additional diagnostic tests were performed in 71.4% of patients before prescription and the most common antibiotic classes prescribed were macrolides (46.0%) and penicillin (42.9%). Important clinical factors for health care providers to prescribe antibiotics were colorised/purulent sputum, abnormal lung sounds during auscultation, fever, and presence of comorbidities. CONCLUSION In 19% of patients with AAEs, antibiotics were prescribed in various classes with a broad range among different subspecialities. This study stresses the urgency to compose evidence-based guidelines to aim for more rational antibiotic prescriptions for AAE.
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Affiliation(s)
- Anne‐Lotte Redel
- Department of PulmonologyFranciscus Gasthuis & VlietlandRotterdamThe Netherlands
- Department of PulmonologyErasmus Medical CenterRotterdamThe Netherlands
| | - Wojciech Feleszko
- Department of Pediatric Allergy and PneumonologyMedical University of WarsawWarsawPoland
| | - Alessandra Arcolaci
- Immunology UnitUniversity of Verona and General Hospital Borgo Roma HospitalVeronaItaly
| | | | | | - Gert‐Jan Braunstahl
- Department of PulmonologyFranciscus Gasthuis & VlietlandRotterdamThe Netherlands
- Department of PulmonologyErasmus Medical CenterRotterdamThe Netherlands
| | - Cristina Boccabella
- Faculty of Medicine and SurgeryRespiratory MedicineCatholic University of the Sacred HeartMilanItaly
| | - Matteo Bonini
- Department of Cardiovascular and Thoracic SciencesUniversità Cattolica del Sacro CuoreFondazione Policlinico Universitario A. Gemelli ‐ IRCCSRomeItaly
- National Heart and Lung InstituteRoyal Brompton Hospital & Imperial College LondonLondonUK
| | - Aspasia Karavelia
- Department of Ear‐Nose‐Throat SurgeryGeneral Hospital of NafplioNafplioGreece
| | - Eefje Louwers
- General PracticeGezondheidscentrum Berkel en RodenrijsBerkel en RodenrijsThe Netherlands
| | | | - Liam O'Mahony
- Department of MedicineSchool of MicrobiologyAPC Microbiome IrelandNational University of IrelandCorkIreland
| | - Laura Pini
- Department of Clinical and Experimental SciencesRespiratory Medicine UnitUniversity of BresciaASST Spedali Civili di BresciaBresciaItaly
| | - Anna Rapiejko
- Department of Pediatric Allergy and PneumonologyMedical University of WarsawWarsawPoland
| | - Esmeralda Shehu
- Internal Medicine DepartmentDurres Regional HospitalDurresAlbania
| | - Milena Sokolowska
- Swiss Institute of Allergy and Asthma Research (SIAF)University of ZurichZürichSwitzerland
| | - Eva Untersmayr
- Institute of Pathophysiology and Allergy ResearchCenter of PathophysiologyInfectiology and ImmunologyMedical University of ViennaViennaAustria
| | - Gerdien Tramper‐Stranders
- Department of PulmonologyErasmus Medical CenterRotterdamThe Netherlands
- Department of PediatricsFranciscus Gasthuis & VlietlandRotterdamThe Netherlands
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Liu L, Wang L, Zhou H, Yang J, Wang W, Luo X, Chang Y. Feedback Intervention for the Control of Glucocorticoid Prescription in Primary Care Institutions: A Cluster Randomized Cross-Over Controlled Trial in Southwest China. Risk Manag Healthc Policy 2024; 17:49-63. [PMID: 38196917 PMCID: PMC10775693 DOI: 10.2147/rmhp.s441165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 12/17/2023] [Indexed: 01/11/2024] Open
Abstract
Purpose The purpose of this study is to assess the effect of glucocorticoid prescription feedback intervention in complex primary care institutions for regulating its inappropriate use. Design Setting and Interventions A six-month cluster randomized cross-over controlled trial was conducted in primary care institutions. A total of 347 physicians from 69 participating institutions were randomly allocated to either group A or group B. Both groups were given feedback interventions or serve as control. The feedback intervention comprised two components: a real-time pop-up warning of inappropriate glucocorticoid prescriptions based on the Hospital Information System and a high-proportion prescription feedback intervention warning system. Outcome Measures The primary outcome measure was the 10-day inappropriate glucocorticoid prescription rate, while the 10-day glucocorticoid prescription rate served as secondary outcome measure. Results At baseline, the 10-day inappropriate glucocorticoid prescription rates were 66.63% and 66.57% in group A and group B, respectively, showing no significant difference (p = 0.140). Following the intervention, group A exhibited a significant reduction in 10-day inappropriate glucocorticoid prescription rate at the crossing point by 13.69% (p < 0.001). In contrast, group B, which served as the control group, experienced an increase of 5.93% (p = 0.037) at the same crossover point. After the crossover point, there was a decrease in 10-day inappropriate glucocorticoid prescription rate for both groups. Group B as the intervention group demonstrated a reduction of 28.22% compared to the crossing point (p < 0.001), whereas group A showed a decrease of 12.20% (p = 0.339). The characteristics of physicians did not significantly influence the inappropriate glucocorticoid prescription rate. Conclusion The real-time pop-up warning of inappropriate glucocorticoid prescriptions based on the Hospital Information System and high-proportion prescription feedback intervention warning system can effectively regulate the inappropriate glucocorticoid prescribing behavior of physicians. Trial Registration ISRCTN11747547.
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Affiliation(s)
- Ling Liu
- School of Public Health, the Key Laboratory of Environmental Pollution Monitoring and Disease Control, Ministry of Education, Guizhou Medical University, Guiyang, Guizhou Province, People’s Republic of China
| | - Lei Wang
- Primary Health Department of Guizhou Provincial Health Commission, Guiyang, Guizhou Province, People’s Republic of China
| | - Hanni Zhou
- School of Medicine and Health Management, Guizhou Medical University, Guiyang, Guizhou Province, People’s Republic of China
- Center of Medicine Economics and Management Research, Guizhou Medical University, Guiyang, Guizhou Province, People’s Republic of China
| | - Junli Yang
- School of Medicine and Health Management, Guizhou Medical University, Guiyang, Guizhou Province, People’s Republic of China
| | - Wenju Wang
- School of Public Health, the Key Laboratory of Environmental Pollution Monitoring and Disease Control, Ministry of Education, Guizhou Medical University, Guiyang, Guizhou Province, People’s Republic of China
| | - Xiaobo Luo
- School of Public Health, the Key Laboratory of Environmental Pollution Monitoring and Disease Control, Ministry of Education, Guizhou Medical University, Guiyang, Guizhou Province, People’s Republic of China
| | - Yue Chang
- School of Medicine and Health Management, Guizhou Medical University, Guiyang, Guizhou Province, People’s Republic of China
- Center of Medicine Economics and Management Research, Guizhou Medical University, Guiyang, Guizhou Province, People’s Republic of China
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Schmiemann G, Greser A, Maun A, Bleidorn J, Schuster A, Miljukov O, Rücker V, Klingeberg A, Mentzel A, Minin V, Eckmanns T, Heintze C, Heuschmann P, Gágyor I. Effects of a multimodal intervention in primary care to reduce second line antibiotic prescriptions for urinary tract infections in women: parallel, cluster randomised, controlled trial. BMJ 2023; 383:e076305. [PMID: 37918836 PMCID: PMC10620739 DOI: 10.1136/bmj-2023-076305] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/25/2023] [Indexed: 11/04/2023]
Abstract
OBJECTIVES To evaluate whether a multimodal intervention in general practice reduces the proportion of second line antibiotic prescriptions and the overall proportion of antibiotic prescriptions for uncomplicated urinary tract infections in women. DESIGN Parallel, cluster randomised, controlled trial. SETTING General practices in five regions in Germany. Data were collected between 1 April 2021 and 31 March 2022. PARTICIPANTS General practitioners from 128 randomly assigned practices. INTERVENTIONS Multimodal intervention consisting of guideline recommendations for general practitioners and patients, provision of regional data for antibiotic resistance, and quarterly feedback, which included individual first line and second line proportions of antibiotic prescribing, benchmarking with regional or supra-regional practices, and telephone counselling. Participants in the control group received no information on the intervention. MAIN OUTCOME MEASURES Primary outcome was the proportion of second line antibiotics prescribed by general practices, in relation to all antibiotics prescribed, for uncomplicated urinary tract infections after one year between the intervention and control group. General practices were randomly assigned in blocks (1:1), with a block size of four, into the intervention or control group using SAS version 9.4; randomisation was stratified by region. The secondary outcome was the prescription proportion of all antibiotics, relative within all cases (instances of UTI diagnosis), for the treatment of urinary tract infections after one year between the groups. Adverse events were assessed as exploratory outcomes. RESULTS 110 practices with full datasets identified 10 323 cases during five quarters (ie, 15 months). The mean proportion of second line antibiotics prescribed was 0.19 (standard deviation 0.20) in the intervention group and 0.35 (0.25) in the control group after 12 months. After adjustment for preintervention proportions, the mean difference was -0.13 (95% confidence interval -0.21 to -0.06, P<0.001). The overall proportion of all antibiotic prescriptions for urinary tract infections over 12 months was 0.74 (standard deviation 0.22) in the intervention and 0.80 (0.15) in the control group with a mean difference of -0.08 (95% confidence interval -0.15 to -0.02, P<0.029). No differences were noted in the number of complications (ie, pyelonephritis, admission to hospital, or fever) between the groups. CONCLUSIONS The multimodal intervention in general practice significantly reduced the proportion of second line antibiotics and all antibiotic prescriptions for uncomplicated urinary tract infections in women. TRIAL REGISTRATION German Clinical Trials Register (DRKS), DRKS00020389.
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Affiliation(s)
- Guido Schmiemann
- University of Bremen, Department of Health Services Research, Institute for Public Health and Nursing Research, Bremen, Germany
| | - Alexandra Greser
- University Hospital Wurzburg, Department of General Practice, Wurzburg, Germany
| | - Andy Maun
- Institute of General Practice/Primary Care, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
| | - Jutta Bleidorn
- University Hospital Jena, Institute of General Practice, Jena, Thuringia, Germany
| | - Angela Schuster
- Charité-Universitätsmedizin Berlin, Institute of General Practice and Family Medicine, Berlin, Germany
| | - Olga Miljukov
- Clinical Trial Centre Wurzburg, University Hospital Wurzburg, Germany
- Institute for Medical Data Sciences, University Hospital Wurzburg, Germany
- Julius-Maximilians-University of Wurzburg, Institute for Clinical Epidemiology and Biometry (ICE-B), Wurzburg, Germany
| | - Viktoria Rücker
- Clinical Trial Centre Wurzburg, University Hospital Wurzburg, Germany
- Institute for Medical Data Sciences, University Hospital Wurzburg, Germany
- Julius-Maximilians-University of Wurzburg, Institute for Clinical Epidemiology and Biometry (ICE-B), Wurzburg, Germany
| | | | - Anja Mentzel
- Institute of General Practice/Primary Care, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
| | - Vitalii Minin
- Institute of General Practice/Primary Care, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
| | | | - Christoph Heintze
- Charité-Universitätsmedizin Berlin, Institute of General Practice and Family Medicine, Berlin, Germany
| | - Peter Heuschmann
- Clinical Trial Centre Wurzburg, University Hospital Wurzburg, Germany
- Institute for Medical Data Sciences, University Hospital Wurzburg, Germany
- Julius-Maximilians-University of Wurzburg, Institute for Clinical Epidemiology and Biometry (ICE-B), Wurzburg, Germany
| | - Ildikó Gágyor
- University Hospital Wurzburg, Department of General Practice, Wurzburg, Germany
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Velly L, Cancella de Abreu M, Boutolleau D, Cherubini I, Houas E, Aurousseau A, Hausfater P. Point-of-care multiplex molecular diagnosis coupled with procalcitonin-guided algorithm for antibiotic stewardship in lower respiratory tract infection: a randomized controlled trial. Clin Microbiol Infect 2023; 29:1409-1416. [PMID: 37549731 DOI: 10.1016/j.cmi.2023.07.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 07/25/2023] [Accepted: 07/29/2023] [Indexed: 08/09/2023]
Abstract
OBJECTIVE We aimed to show that coupling molecular syndromic respiratory panel (RP) testing with procalcitonin (PCT) measurement in the emergency department improves antibiotic (ATB) stewardship in lower respiratory tract infection. METHODS Open-label, prospective, randomized interventional trial, conducted from 2019 to 2022 in an adult emergency department. Patients with a suspicion of lower respiratory tract infection were randomized into an intervention arm (PCT measurement and point-of-care BIOFIRE RP2.1 plus testing, accompanied by a recommended ATB algorithm) or a standard of care (SOC) arm (PCT allowed as current practice). The primary endpoint was the duration of antibiotic exposure. RESULTS Four hundred fifty-one patients were randomized, median age 65 years (Q1-Q3: 49-77), the hospitalization rate was 59.9% (270/451), the median length of stay 5 days (Q1-Q3: 3 - 12), and the 28-day mortality rate 5.3% (23/451). The median duration of ATB exposure was 6 days (Q1-Q3: 0-9) and 5 days (Q1-Q3: 0-9) in the SOC and interventional arm respectively (p = 0.71). ATB was started in 29.6 % (67/226) and 33.8% (76/225) respectively (p = 0.54). The BIOFIRE RP2.1 plus identified at least one viral species in 112/225 patients (49.8%) of intervention arm. Two hundred twelve out of two hundred twenty-six (93.8%) SOC patients had PCT measurement. The adherence rate to algorithm in the intervention arm was 93.3 % (210/225). CONCLUSION Displaying PCT and real-time RP results to emergency physicians failed to significantly reduce ATB exposure in lower respiratory tract infection suspicions. However, the median ATB duration and rate of initiation were already low in the SOC arm using PCT measurement routinely.
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Affiliation(s)
- Laetitia Velly
- Emergency Department, APHP-Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France; GRC-14 BIOSFAST, CIMI, UMR 1135, Sorbonne Université, Paris, France
| | - Marta Cancella de Abreu
- Emergency Department, APHP-Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France; GRC-14 BIOSFAST, CIMI, UMR 1135, Sorbonne Université, Paris, France
| | - David Boutolleau
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique (iPLESP), GH AP-HP. Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Virologie, Paris, France
| | - Ilaria Cherubini
- Emergency Department, APHP-Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France
| | - Enfel Houas
- Emergency Department, APHP-Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France
| | | | - Pierre Hausfater
- Emergency Department, APHP-Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France; GRC-14 BIOSFAST, CIMI, UMR 1135, Sorbonne Université, Paris, France.
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Last K, Simon A, Gärtner BC, Becker SL, Papan C. Attitudes of primary care physicians towards antimicrobial stewardship and the impact of a multi-part training course - a pilot study. GMS HYGIENE AND INFECTION CONTROL 2023; 18:Doc24. [PMID: 38025891 PMCID: PMC10665713 DOI: 10.3205/dgkh000450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
Background A plethora of antimicrobial stewardship (AMS) programs has been initiated during the past years, focusing on hospital settings. Primary-care physicians have seldom been addressed, although the majority of antibiotic prescriptions are issued for outpatients. We sought to investigate attitudes of primary-care physicians and the impact of a customized training course. Methods Primary-care physicians in southwest Germany were invited to a multi-part training course on AMS in the primary-care setting. Participants were asked to answer a questionnaire about their attitude and factors that hinder them from implementing AMS or enable them to perform AMS. In addition, a knowledge assessment exam at the beginning and end of the training was conducted on selected infectious diseases/syndromes. Results In total, 36 primary-care physicians participated in the training course. The predominant age group was 51-60 years old (36%; 13/36). The majority, 23/35 (66%), indicated never having had AMS training, while 22/35 (63%) acknowledged partly implementing AMS activities in their daily routine. The primary barrier was lack of expertise, while the main motives were reducing antimicrobial resistance and optimizing patient care. The provision of guidelines was regarded as more important than feedback on their prescription behavior. Exam performance improved from the initial to the final exam on all topics. Conclusion Customized AMS training courses are a feasible and potentially complimentary tool to address antibiotic misuse in the primary-care setting.
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Affiliation(s)
- Katharina Last
- Institute for Hygiene and Public Health, University Hospital Bonn, Bonn, Germany
- Center for Infectious Diseases, Institute of Medical Microbiology and Hygiene, Saarland University, Homburg, Germany
| | - Arne Simon
- Pediatric Oncology, Saarland University Medical Center, Homburg, Germany
| | - Barbara C. Gärtner
- Center for Infectious Diseases, Institute of Medical Microbiology and Hygiene, Saarland University, Homburg, Germany
| | - Sören L. Becker
- Center for Infectious Diseases, Institute of Medical Microbiology and Hygiene, Saarland University, Homburg, Germany
| | - Cihan Papan
- Institute for Hygiene and Public Health, University Hospital Bonn, Bonn, Germany
- Center for Infectious Diseases, Institute of Medical Microbiology and Hygiene, Saarland University, Homburg, Germany
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Schwartz KL, Xu AXT, Alderson S, Bjerrum L, Brehaut J, Brown BC, Bucher HC, De Sutter A, Francis N, Grimshaw J, Gunnarsson R, Hoye S, Ivers N, Lecky DM, Lindbæk M, Linder JA, Little P, Michalsen BO, O'Connor D, Pulcini C, Sundvall PD, Lundgren PT, Verbakel JY, Verheij TJ. Best practice guidance for antibiotic audit and feedback interventions in primary care: a modified Delphi study from the Joint Programming Initiative on Antimicrobial resistance: Primary Care Antibiotic Audit and Feedback Network (JPIAMR-PAAN). Antimicrob Resist Infect Control 2023; 12:72. [PMID: 37516892 PMCID: PMC10387210 DOI: 10.1186/s13756-023-01279-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 07/21/2023] [Indexed: 07/31/2023] Open
Abstract
BACKGROUND Primary care is a critical partner for antimicrobial stewardship efforts given its high human antibiotic usage. Peer comparison audit and feedback (A&F) is often used to reduce inappropriate antibiotic prescribing. The design and implementation of A&F may impact its effectiveness. There are no best practice guidelines for peer comparison A&F in antibiotic prescribing in primary care. OBJECTIVE To develop best practice guidelines for peer comparison A&F for antibiotic prescribing in primary care in high income countries by leveraging international expertise via the Joint Programming Initiative on Antimicrobial Resistance-Primary Care Antibiotic Audit and Feedback Network. METHODS We used a modified Delphi process to achieve convergence of expert opinions on best practice statements for peer comparison A&F based on existing evidence and theory. Three rounds were performed, each with online surveys and virtual meetings to enable discussion and rating of each best practice statement. A five-point Likert scale was used to rate consensus with a median threshold score of 4 to indicate a consensus statement. RESULTS The final set of guidelines include 13 best practice statements in four categories: general considerations (n = 3), selecting feedback recipients (n = 1), data and indicator selection (n = 4), and feedback delivery (n = 5). CONCLUSION We report an expert-derived best practice recommendations for designing and evaluating peer comparison A&F for antibiotic prescribing in primary care. These 13 statements can be used by A&F designers to optimize the impact of their quality improvement interventions, and improve antibiotic prescribing in primary care.
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Affiliation(s)
- Kevin L Schwartz
- Public Health Ontario, 480 University Ave, Ste 300, Toronto, ON, M5G 1V2, Canada.
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.
- Unity Health Toronto, Toronto, Canada.
| | - Alice X T Xu
- Public Health Ontario, 480 University Ave, Ste 300, Toronto, ON, M5G 1V2, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Sarah Alderson
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
- Oaklands Health Centre, Holmfirth, UK
| | - Lars Bjerrum
- Section of General Practice and Research Unit for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Jamie Brehaut
- Centre for Practice-Changing Research (CPCR), Ottawa Hospital Research Institute, Ottawa, Canada
| | - Benjamin C Brown
- Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, University of Manchester, Manchester, UK
| | - Heiner C Bucher
- Division of Clinical Epidemiology, University Hospital Basel and University of Basel, Basel, Switzerland
| | - An De Sutter
- Department of Public Health and Primary Care, Center for Family Medicine UGent, Ghent University, Ghent, Belgium
| | - Nick Francis
- Primary Care Research Centre, University of Southampton, Southampton, UK
| | - Jeremy Grimshaw
- Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Ronny Gunnarsson
- General Practice/Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Gothenburg, Sweden
- Centre for Antibiotic Resistance Research (CARe) at University of Gothenburg, Gothenburg, Sweden
| | - Sigurd Hoye
- Department of General Practice, Antibiotic Centre for Primary Care, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Noah Ivers
- Women's College Hospital, Toronto, Canada
| | - Donna M Lecky
- Primary Care and Interventions Unit, UK Health Security Agency, Gloucester, England
| | - Morten Lindbæk
- Department of General Practice, Antibiotic Centre for Primary Care, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Jeffrey A Linder
- Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Paul Little
- Primary Care Research Centre, University of Southampton, Southampton, England
| | - Benedikte Olsen Michalsen
- Department of General Practice, Antibiotic Centre for Primary Care, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Denise O'Connor
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Celine Pulcini
- APEMAC, Université de Lorraine, Nancy, France
- CHRU-Nancy, Centre regional en antibiotherapie de la region Grand Est AntibioEst, Université de Lorraine, Nancy, France
| | - Pär-Daniel Sundvall
- General Practice/Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Gothenburg, Sweden
- Centre for Antibiotic Resistance Research (CARe) at University of Gothenburg, Gothenburg, Sweden
| | | | - Jan Y Verbakel
- Department of Public Health and Primary Care, KU Leuven, Louvain, Belgium
- NIHR Community Healthcare Medtech and IVD Cooperative, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Theo J Verheij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
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10
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Michalsen BO, Xu AXT, Alderson SL, Bjerrum L, Brehaut J, Bucher HC, Clarkson J, Duncan E, Grimshaw J, Gunnarsson R, Høye S, Ivers N, Lecky DM, Lindbæk M, Llor C, Lundgren PT, O’connor D, Pulcini C, Ramsay C, Sundvall PD, Verheij T, Schwartz KL. Regional and national antimicrobial stewardship activities: a survey from the Joint Programming Initiative on Antimicrobial Resistance-Primary Care Antibiotic Audit and Feedback Network (JPIAMR-PAAN). JAC Antimicrob Resist 2023; 5:dlad048. [PMID: 38659427 PMCID: PMC10123362 DOI: 10.1093/jacamr/dlad048] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 03/27/2023] [Indexed: 04/16/2024] Open
Abstract
Background Antibiotic overuse and misuse in primary care are common, highlighting the importance of antimicrobial stewardship (AMS) efforts in this setting. Audit and feedback (A&F) interventions can improve professional practice and performance in some settings. Objectives and methods To leverage the expertise from international members of the Joint Programming Initiative on Antimicrobial Resistance - Primary care Antibiotic Audit and feedback Network (JPIAMR-PAAN). Network members all have experience of designing and delivering A&F interventions to reduce inappropriate antibiotic prescribing in primary care settings. We aim to introduce the network and explore ongoing A&F activities in member regions. An online survey was administered to all network members to collect regional information. Results Fifteen respondents from 11 countries provided information on A&F activities in their country, and national/regional antibiotic stewardship programmes or policies. Most countries use electronic medical records as the primary data source, antibiotic appropriateness as the main outcome of feedback, and target GPs as the prescribers of interest. Funding sources varied across countries, which could influence the frequency and quality of A&F interventions. Nine out of 11 countries reported having a national antibiotic stewardship programme or policy, which aim to provide systematic support to ongoing AMS efforts and aid sustainability. Conclusions The survey identified gaps and opportunities for AMS efforts that include A&F across member countries in Europe, Canada and Australia. JPIAMR-PAAN will continue to leverage its members to produce best practice resources and toolkits for antibiotic A&F interventions in primary care settings and identify research priorities.
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Affiliation(s)
- Benedikte Olsen Michalsen
- Antibiotic Centre for Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Alice X T Xu
- Health Protection, Public Health Ontario, Toronto, Canada
- Public Health Sciences, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Sarah L Alderson
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
- Oaklands Health Centre, Holmfirth, UK
| | - Lars Bjerrum
- Section of General Practice and Research Unit for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Jamie Brehaut
- Centre for Practice-Changing Research (CPCR), Ottawa Hospital Research Institute, Ottawa, Canada
| | - Heiner C Bucher
- University of Basel, c/o Division of Clinical Epidemiology, Basel, Switzerland
| | - Janet Clarkson
- University of Dundee, NHS Education for Scotland, Dundee, UK
| | - Eilidh Duncan
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Jeremy Grimshaw
- Department of Medicine, University of Ottawa Canada Research Chair in Health Knowledge Transfer and Uptake, Ottawa, Canada
| | - Ronny Gunnarsson
- General Practice/Family medicine, Department of Public Health and Community Medicine, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Goteborg, Sweden
- Centre for Antibiotic Resistance Research (CARe) at University of Gothenburg, Gothenburg, Sweden
| | - Sigurd Høye
- Antibiotic Centre for Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Noah Ivers
- Department of Family Medicine, Women’s College Hospital, Toronto, Canada
| | - Donna M Lecky
- Primary Care & Interventions Unit, UK Health Security Agency, Gloucester, UK
| | - Morten Lindbæk
- Antibiotic Centre for Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Carl Llor
- Department is University Institute in Primary Care Research, University Institute in Primary Care Research Jordi Gol, Via Roma Health Centre, Barcelona, Spain
- CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
- Research Unit for General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | | | - Denise O’connor
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, 3004, Australia
| | - Celiné Pulcini
- Public Health Research Unit, Université de Lorraine, APEMAC, Nancy, France
- CHRU-Nancy, Université de Lorraine, Service de Maladies Infectieuses et Tropicales, Nancy, France
| | - Craig Ramsay
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Pär-Daniel Sundvall
- General Practice/Family medicine, Department of Public Health and Community Medicine, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Goteborg, Sweden
- Centre for Antibiotic Resistance Research (CARe) at University of Gothenburg, Gothenburg, Sweden
| | - Theo Verheij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrect, The Netherlands
| | - Kevin L Schwartz
- Health Protection, Public Health Ontario, Toronto, Canada
- Public Health Sciences, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Division of Infectious Diseases, St. Joseph's Health Centre - Unity Health Toronto, Toronto, Ontario, Canada
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11
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Linder JA, Fox CR. Simplicity Matters-Overengineering Feedback Can Be Counterproductive. JAMA Intern Med 2023; 183:220-222. [PMID: 36877210 DOI: 10.1001/jamainternmed.2022.6528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Affiliation(s)
- Jeffrey A Linder
- Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Craig R Fox
- Behavioral Decision Making Area, Anderson School of Management, University of California, Los Angeles
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