1
|
Bienvenu AL, Leray V, Guichon C, Bourget S, Chapuis C, Duréault A, Pavese P, Roux S, Kahale E, Chaabane W, Subtil F, Maucort-Boulch D, Talbot F, Dode X, Ghesquières H, Leboucher G. ANTIFON-CLIC®, a new clinical decision support system for the treatment of invasive aspergillosis: is it clinically relevant? ANNALES PHARMACEUTIQUES FRANÇAISES 2024; 82:514-521. [PMID: 38000506 DOI: 10.1016/j.pharma.2023.11.002] [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: 10/31/2023] [Revised: 11/17/2023] [Accepted: 11/20/2023] [Indexed: 11/26/2023]
Abstract
BACKGROUND Invasive aspergillosis (IA) is increasing especially in new groups of patients. Despite advances in management, morbidity and mortality related to IA remain high. Thus, Clinical Decision Support System (CDSS) dedicated to IA are needed to promote the optimal antifungal for each group of patients. PATIENTS AND METHODS This was a retrospective multicenter cohort study involving intensive care units and medical units. Adult patients who received caspofungin, isavuconazole, itraconazole, liposomal amphotericin B, posaconazole, or voriconazole, for the treatment of IA were eligible for enrollment. The primary objective was the concordance between the clinician's prescription and the prescription recommended by the CDSS. The secondary objective was the concordance according to different hospitals, departments, and indications. RESULTS Eighty-eight patients (n=88) from three medical hospitals were included. The overall concordance was 97% (85/88) including 100% (41/41) for center A, 92% (23/25) for center B, and 95% (21/22) for center C. There was no significant difference in concordance among the hospitals (P=0.973), the departments (P=1.000), and the indications (P=0.799). The concordance was 70% (7/10) for isavuconazole due to its use as an empirical treatment and 100% (78/78) for the other antifungals. DISCUSSION The concordance rate was high whatever the hospital, the department, and the indication. The only discrepancy was attributed to the use of isavuconazole as an empirical treatment which is a therapeutic option not included in the CDSS. CONCLUSIONS This new CDSS dedicated to IA is meeting the clinical practice. Its implementation in routine will help to support antifungal stewardship.
Collapse
Affiliation(s)
- A-L Bienvenu
- Service pharmacie, groupement hospitalier nord, hospices civils de Lyon, Lyon, France; Univ Lyon, Malaria Research Unit, SMITh, ICBMS UMR 5246, Lyon, France.
| | - V Leray
- Service d'anesthésie-réanimation, groupement hospitalier centre, hospices civils de Lyon, Lyon, France
| | - C Guichon
- Service d'anesthésie-réanimation, groupement hospitalier nord, Hospices civils de Lyon, Lyon, France
| | - S Bourget
- Service pharmacie, CH de Valence, Valence, France
| | - C Chapuis
- Service de pharmacie, CHU de Grenoble, Grenoble-Alpes, France
| | - A Duréault
- Service des maladies infectieuses, centre hospitalier de Valence, Valence, France
| | - P Pavese
- Service des maladies infectieuses, CHU de Grenoble, Grenoble-Alpes, France
| | - S Roux
- Service des maladies infectieuses et tropicales, hospices civils de Lyon, Lyon, France
| | - E Kahale
- Direction de l'innovation, hospices civils de Lyon, Lyon, France
| | - W Chaabane
- Direction des services numériques, hospices civils de Lyon, Lyon, France
| | - F Subtil
- Service de biostatistique-bioinformatique, hospices civils de Lyon, Lyon, France
| | - D Maucort-Boulch
- Service de biostatistique-bioinformatique, hospices civils de Lyon, Lyon, France
| | - F Talbot
- Direction des services numériques, hospices civils de Lyon, Lyon, France
| | - X Dode
- Service pharmacie, groupement hospitalier est, hospices civils de Lyon, Lyon, France
| | - H Ghesquières
- Service d'hématologie, groupement hospitalier sud, hospices civils de Lyon, Lyon, France
| | - G Leboucher
- Service pharmacie, groupement hospitalier nord, hospices civils de Lyon, Lyon, France
| |
Collapse
|
2
|
Carville KS, Meagher N, Abo YN, Manski-Nankervis JA, Fielding J, Steer A, McVernon J, Price DJ. Burden of antimicrobial prescribing in primary care attributable to sore throat: a retrospective cohort study of patient record data. BMC PRIMARY CARE 2024; 25:117. [PMID: 38632513 PMCID: PMC11022400 DOI: 10.1186/s12875-024-02371-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 04/08/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND Reducing antibiotic use in Australia, and the subsequent impact on antimicrobial resistance, requires multiple, sustained approaches with appropriate resources and support. Additional strategies to reduce antibiotic prescribing include effective vaccines, against pathogens such as Streptococcus pyogenes, the most common bacterial cause of sore throat. As part of efforts towards assessing the benefits of introducing new strategies to reduce antimicrobial prescribing, we aimed to determine the burden of antimicrobial prescribing for sore throat in general practice. METHODS General practice activity data from 2013 - 2017 derived from the first 8 practices participating in the 'Primary Care Audit, Teaching and Research Open Network' (Patron) program were analysed according to reason for visit (upper respiratory tract infection, URTI, or sore throat) and antibiotic prescription. The main outcome measures were percentage of sore throat or URTI presentations with antibiotic prescription by age. RESULTS A total of 722,339 visits to general practice were made by 65,449 patients; 5.7% of visits were for URTI with 0.8% meeting the more specific criteria for sore throat. 66.1% of sore throat visits and 36.2% of URTI visits resulted in antibiotic prescription. Penicillin, the recommended antibiotic for sore throat when indicated, was the antibiotic of choice in only 52.9% of sore throat cases prescribed antibiotics. Broader spectrum antibiotics were prescribed more frequently in older age groups. CONCLUSIONS Frequency of antibiotic prescribing for sore throat is high and broad, despite Australian Therapeutic guideline recommendations. Multiple, sustained interventions to reduce prescribing, including availability of effective S. pyogenes vaccines that could reduce the incidence of streptococcal pharyngitis, could obviate the need to prescribe antibiotics and support ongoing efforts to promote antimicrobial stewardship.
Collapse
Affiliation(s)
- Kylie S Carville
- Doherty Epidemiology, Victorian Infectious Diseases Reference Laboratory, at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
- Department of Infectious Diseases, The University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Niamh Meagher
- Department of Infectious Diseases, The University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia.
| | - Yara-Natalie Abo
- Department of Microbiology, Infection Prevention and Control, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Jo-Anne Manski-Nankervis
- Department of General Practice and Primary Care, The University of Melbourne, Melbourne, Victoria, Australia
| | - James Fielding
- Doherty Epidemiology, Victorian Infectious Diseases Reference Laboratory, at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
- Department of Infectious Diseases, The University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Andrew Steer
- Centre for International Child Health, Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
| | - Jodie McVernon
- Doherty Epidemiology, Victorian Infectious Diseases Reference Laboratory, at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
- Department of Infectious Diseases, The University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - David J Price
- Department of Infectious Diseases, The University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| |
Collapse
|
3
|
Attal H, Huang Z, Kuan WS, Weng Y, Tan HY, Seow E, Peng LL, Lim HC, Chow A. N-of-1 Trials of Antimicrobial Stewardship Interventions to Optimize Antibiotic Prescribing for Upper Respiratory Tract Infection in Emergency Departments: Protocol for a Quasi-Experimental Study. JMIR Res Protoc 2024; 13:e50417. [PMID: 38381495 PMCID: PMC10918537 DOI: 10.2196/50417] [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: 06/30/2023] [Revised: 01/27/2024] [Accepted: 01/29/2024] [Indexed: 02/22/2024] Open
Abstract
BACKGROUND Antimicrobial stewardship programs attempting to optimize antibiotic therapy and clinical outcomes mainly focus on inpatient and outpatient settings. The lack of antimicrobial stewardship program studies in the emergency department (ED) represents a gap in tackling the problem of antimicrobial resistance as EDs treat a substantial number of upper respiratory tract infection cases throughout the year. OBJECTIVE We intend to implement two evidence-based interventions: (1) patient education and (2) providing physician feedback on their prescribing rates. We will incorporate evidence from a literature review and contextualizing the interventions based on findings from a local qualitative study. METHODS Our study uses a quasi-experimental design to evaluate the effects of interventions over time in the EDs of 4 public hospitals in Singapore. We will include an initial control period of 18 months. In the next 6 months, we will randomize 2 EDs to receive 1 intervention (ie, patient education) and the other 2 EDs to receive the alternative intervention (ie, physician feedback). All EDs will receive the second intervention in the subsequent 6 months on top of the ongoing intervention. Data will be collected for another 6 months to assess the persistence of the intervention effects. The information leaflets will be handed to patients at the EDs before they consult with the physician, while feedback to individual physicians by senior doctors is in the form of electronic text messages. The feedback will contain the physicians' antibiotic prescribing rate compared with the departments' overall antibiotic prescribing rate and a bite-size message on good antibiotic prescribing practices. RESULTS We will analyze the data using segmented regression with difference-in-difference estimation to account for concurrent cluster comparisons. CONCLUSIONS Our proposed study assesses the effectiveness of evidence-based, context-specific interventions to optimize antibiotic prescribing in EDs. These interventions are aligned with Singapore's national effort to tackle antimicrobial resistance and can be scaled up if successful. TRIAL REGISTRATION ClinicalTrials.gov NCT05451863; https://clinicaltrials.gov/study/NCT05451836. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/50417.
Collapse
Affiliation(s)
- Hersh Attal
- Accident & Emergency Department, Changi General Hospital, Singapore, Singapore
| | - Zhilian Huang
- Department of Preventive and Population Medicine, Office of Clinical Epidemiology, Analytics, and Knowledge, Tan Tock Seng Hospital, Singapore, Singapore
| | - Win Sen Kuan
- Department of Emergency Medicine, National University Hospital, Singapore, Singapore
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Yanyi Weng
- Department of Emergency Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Hann Yee Tan
- Acute and Emergency Care Department, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Eillyne Seow
- Acute and Emergency Care Department, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Li Lee Peng
- Department of Emergency Medicine, National University Hospital, Singapore, Singapore
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Hoon Chin Lim
- Accident & Emergency Department, Changi General Hospital, Singapore, Singapore
| | - Angela Chow
- Department of Preventive and Population Medicine, Office of Clinical Epidemiology, Analytics, and Knowledge, Tan Tock Seng Hospital, Singapore, Singapore
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| |
Collapse
|
4
|
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.
Collapse
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
| |
Collapse
|
5
|
Campbell A, Borek AJ, McLeod M, Tonkin-Crine S, Pouwels KB, Roope LS, Hayhoe BW, Majeed A, Walker AS, Holmes A. Impact of the COVID-19 pandemic on antimicrobial stewardship support for general practices in England: a qualitative interview study. BJGP Open 2023; 7:BJGPO.2022.0193. [PMID: 37290780 PMCID: PMC10646204 DOI: 10.3399/bjgpo.2022.0193] [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: 12/22/2022] [Revised: 04/13/2023] [Accepted: 05/02/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND In England, clinical commissioning group (CCG; now replaced by Integrated Care Systems [ICSs]) and primary care network (PCN) professionals support primary care prescribers to optimise antimicrobial stewardship (AMS). AIM To explore views and experiences of CCG and PCN staff in supporting AMS, and the impact of COVID-19 on this support. DESIGN & SETTING Qualitative interview study in primary care in England. METHOD Semi-structured interviews with staff from CCG and PCNs responsible for AMS were conducted at two timepoints via telephone. These were audio-recorded, transcribed, and analysed thematically. RESULTS Twenty-seven interviews were conducted with 14 participants (nine CCG, five PCN) in December 2020-January 2021 and February-May 2021. The study found that AMS support was (1) deprioritised in order to keep general practice operational and deliver COVID-19 vaccines; (2) disrupted as social distancing made it harder to build relationships, conduct routine AMS activities, and challenge prescribing decisions; and (3) adapted, with opportunities identified for greater use of technology and changing patient and public perceptions of viruses and self-care. It was also found that resources to support AMS were valued if they were both novel, to counter AMS 'fatigue', and sufficiently familiar to fit with existing and/or future AMS. CONCLUSION AMS needs to be reprioritised in general practice in the post-pandemic era and within the new ICSs in England. This should include interventions and strategies that combine novel elements with already familiar strategies to refresh prescribers' motivation and opportunities for AMS. Behaviour change interventions should be aimed at improving the culture and processes for how PCN pharmacists voice concerns about AMS to prescribers in general practice and take advantage of the changed patient and public perceptions of viruses and self-care.
Collapse
Affiliation(s)
- Anne Campbell
- National Institute for Health Research (NIHR), Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
| | - Aleksandra J Borek
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Monsey McLeod
- National Institute for Health Research (NIHR), Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
- Centre for Medication Safety and Service Quality, Pharmacy Department, Imperial College Healthcare NHS Trust, London, UK
- NIHR Imperial Patient Safety Translational Research Centre, Imperial College London, London, UK
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
| | - Koen B Pouwels
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Laurence Sj Roope
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Azeem Majeed
- Primary Care and Public Health, Imperial College London, London, UK
| | - A Sarah Walker
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Alison Holmes
- National Institute for Health Research (NIHR), Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
| |
Collapse
|
6
|
Implementing antibiotic stewardship in high-prescribing English general practices: a mixed-methods study. Br J Gen Pract 2023; 73:e164-e175. [PMID: 36823061 PMCID: PMC9975978 DOI: 10.3399/bjgp.2022.0298] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 10/14/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Trials have identified antimicrobial stewardship (AMS) strategies that effectively reduce antibiotic use in primary care. However, many are not commonly used in England. The authors co-developed an implementation intervention to improve use of three AMS strategies: enhanced communication strategies, delayed prescriptions, and point-of-care C-reactive protein tests (POC-CRPTs). AIM To investigate the use of the intervention in high-prescribing practices and its effect on antibiotic prescribing. DESIGN AND SETTING Nine high-prescribing practices had access to the intervention for 12 months from November 2019. This was primarily delivered remotely via a website with practices required to identify an 'antibiotic champion'. METHOD Routinely collected prescribing data were compared between the intervention and the control practices. Intervention use was assessed through monitoring. Surveys and interviews were conducted with professionals to capture experiences of using the intervention. RESULTS There was no evidence that the intervention affected prescribing. Engagement with intervention materials differed substantially between practices and depended on individual champions' preconceptions of strategies and the opportunity to conduct implementation tasks. Champions in five practices initiated changes to encourage use of at least one AMS strategy, mostly POC-CRPTs; one practice chose all three. POC-CRPTs was used more when allocated to one person. CONCLUSION Clinicians need detailed information on exactly how to adopt AMS strategies. Remote, one-sided provision of AMS strategies is unlikely to change prescribing; initial clinician engagement and understanding needs to be monitored to avoid misunderstanding and suboptimal use.
Collapse
|
7
|
Leung T, Dauber-Decker K, Solomon J, Khan S, Barnaby D, Chelico J, Qiu M, Liu Y, Mann D, Pekmezaris R, McGinn T, Diefenbach M. Nudging Health Care Providers' Adoption of Clinical Decision Support: Protocol for the User-Centered Development of a Behavioral Economics-Inspired Electronic Health Record Tool. JMIR Res Protoc 2023; 12:e42653. [PMID: 36652293 PMCID: PMC9892982 DOI: 10.2196/42653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 10/21/2022] [Accepted: 10/25/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The improvements in care resulting from clinical decision support (CDS) have been significantly limited by consistently low health care provider adoption. Health care provider attitudes toward CDS, specifically psychological and behavioral barriers, are not typically addressed during any stage of CDS development, although they represent an important barrier to adoption. Emerging evidence has shown the surprising power of using insights from the field of behavioral economics to address psychological and behavioral barriers. Nudges are formal applications of behavioral economics, defined as positive reinforcement and indirect suggestions that have a nonforced effect on decision-making. OBJECTIVE Our goal is to employ a user-centered design process to develop a CDS tool-the pulmonary embolism (PE) risk calculator-for PE risk stratification in the emergency department that incorporates a behavior theory-informed nudge to address identified behavioral barriers to use. METHODS All study activities took place at a large academic health system in the New York City metropolitan area. Our study used a user-centered and behavior theory-based approach to achieve the following two aims: (1) use mixed methods to identify health care provider barriers to the use of an active CDS tool for PE risk stratification and (2) develop a new CDS tool-the PE risk calculator-that addresses behavioral barriers to health care providers' adoption of CDS by incorporating nudges into the user interface. These aims were guided by the revised Observational Research Behavioral Information Technology model. A total of 50 clinicians who used the original version of the tool were surveyed with a quantitative instrument that we developed based on a behavior theory framework-the Capability-Opportunity-Motivation-Behavior framework. A semistructured interview guide was developed based on the survey responses. Inductive methods were used to analyze interview session notes and audio recordings from 12 interviews. Revised versions of the tool were developed that incorporated nudges. RESULTS Functional prototypes were developed by using Axure PRO (Axure Software Solutions) software and usability tested with end users in an iterative agile process (n=10). The tool was redesigned to address 4 identified major barriers to tool use; we included 2 nudges and a default. The 6-month pilot trial for the tool was launched on October 1, 2021. CONCLUSIONS Clinicians highlighted several important psychological and behavioral barriers to CDS use. Addressing these barriers, along with conducting traditional usability testing, facilitated the development of a tool with greater potential to transform clinical care. The tool will be tested in a prospective pilot trial. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/42653.
Collapse
Affiliation(s)
| | | | - Jeffrey Solomon
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | - Sundas Khan
- Baylor College of Medicine, Houston, TX, United States
| | - Douglas Barnaby
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | | | - Michael Qiu
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | - Yan Liu
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | - Devin Mann
- New York University Grossman School of Medicine, New York, NY, United States
| | - Renee Pekmezaris
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | - Thomas McGinn
- Baylor College of Medicine, Houston, TX, United States.,CommonSpirit Health, Chicago, IL, United States
| | - Michael Diefenbach
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| |
Collapse
|
8
|
Danevska M, Pechijareva Sadikarijo I, Sekovska J, Naumovska Z. Knowledge and attitudes of patients for using antibiotics. MAKEDONSKO FARMACEVTSKI BILTEN 2022. [DOI: 10.33320/maced.pharm.bull.2022.68.03.236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Affiliation(s)
- Marijana Danevska
- Agency for drugs and medical devices, Blvd. Ss. Cyril and Methodius 54, 1000 Skopje, R.N. Macedonia
| | | | | | - Zorica Naumovska
- Faculty of Pharmacy, University “Ss Cyril and Methodius”, Mother Theresa 47, 1000 Skopje, Republic of N. Macedonia
| |
Collapse
|
9
|
Cox S, Lo-A-Foe K, van Hoof M, Dinant GJ, Oudhuis G, Savelkoul P, Cals J, de Bont E. Physician-Targeted Interventions in Antibiotic Prescribing for Urinary Tract Infections in General Practice: A Systematic Review. Antibiotics (Basel) 2022; 11:1560. [PMID: 36358215 PMCID: PMC9686805 DOI: 10.3390/antibiotics11111560] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 10/25/2022] [Accepted: 11/03/2022] [Indexed: 07/30/2023] Open
Abstract
Urinary tract infections (UTIs) are the most common reason for women to consult a general practitioner (GP). While UTIs are self-limiting in half of cases, most women are prescribed antibiotics, often in discordance with established guidelines. Researchers have employed different interventions to improve GPs' prescribing behavior, especially for respiratory infections, but it is uncertain whether these are effective for UTI care. Therefore, we performed a systematic review, including (cluster) randomized clinical trials investigating the effect of interventions targeted at GPs to improve antibiotic prescriptions for UTI. From September to December 2021 we searched the Medline, Web of Science, and CENTRAL databases, ultimately including ten studies describing eleven trials. We determined the effect of the interventions on the decision to prescribe and on the choice of antibiotic. Results showed that most studies employed multifaceted interventions, most frequently including audit & feedback and/or educational meetings. Seven out of nine trials that recorded first-choice prescriptions saw an increased proportion of first-choice antibiotics in the intervention groups compared to control groups. The employed interventions also caused a decreased proportion of at least one broad-spectrum antibiotic in five out of six studies that measured broad-spectrum antibiotic prescriptions. However, the total number of antibiotic prescriptions for UTIs increased in four out of eight studies. Therefore, while effective at influencing GPs' prescribing behavior, future interventions should also focus on improving the decision to prescribe at all.
Collapse
Affiliation(s)
- Stefan Cox
- Department of Family Medicine, Maastricht University, P. Debyeplein 1, 6229 HA Maastricht, The Netherlands
| | - Kelly Lo-A-Foe
- Department of Family Medicine, Maastricht University, P. Debyeplein 1, 6229 HA Maastricht, The Netherlands
| | - Minke van Hoof
- Department of Family Medicine, Maastricht University, P. Debyeplein 1, 6229 HA Maastricht, The Netherlands
| | - Geert-Jan Dinant
- Department of Family Medicine, Maastricht University, P. Debyeplein 1, 6229 HA Maastricht, The Netherlands
| | - Guy Oudhuis
- Department of Medical Microbiology, Maastricht University Medical Centre+, Universiteitssingel 40, 6229 ER Maastricht, The Netherlands
| | - Paul Savelkoul
- Department of Medical Microbiology, Maastricht University Medical Centre+, Universiteitssingel 40, 6229 ER Maastricht, The Netherlands
| | - Jochen Cals
- Department of Family Medicine, Maastricht University, P. Debyeplein 1, 6229 HA Maastricht, The Netherlands
| | - Eefje de Bont
- Department of Family Medicine, Maastricht University, P. Debyeplein 1, 6229 HA Maastricht, The Netherlands
| |
Collapse
|
10
|
Evaluation of the Clinical Outcome and Cost Analysis of Antibiotics in the Treatment of Acute Respiratory Tract Infections in the Emergency Department in Saudi Arabia. Antibiotics (Basel) 2022; 11:antibiotics11111478. [PMID: 36358133 PMCID: PMC9686469 DOI: 10.3390/antibiotics11111478] [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: 09/18/2022] [Revised: 10/20/2022] [Accepted: 10/22/2022] [Indexed: 11/17/2022] Open
Abstract
This study aims to assess the prevalence and antibiotic-treatment patterns of respiratory tract infections (RTIs), prevalence and types of antibiotic-prescribing errors, and the cost of inappropriate antibiotic use among emergency department (ED) patients. A cross-sectional study was conducted at the ED in King Abdulaziz Medical City, Riyadh, Saudi Arabia. Patient characteristics (age, sex, weight, allergies, diagnostic tests (CX-Ray), cultures, microorganism types, and prescription characteristics) were studied. During the study, 3185 cases were diagnosed with RTIs: adults (>15 years) 55% and pediatrics (<15 years) 44%. The overall prevalence of RTIs was 21%, differentiated by upper respiratory tract infections (URTI) and lower respiratory tract infections (LRTI) (URTI 13.4%; LRTI 8.4%), of total visits. Three main antibiotics (ATB) categories were prescribed in both age groups: penicillin (pediatrics 43%; adults 26%), cephalosporin (pediatrics 29%; adults 19%), and macrolide (pediatrics 26%; adults 38%). The prevalence of inappropriate ATB prescriptions was 53% (pediatrics 35%; adults 67%). Errors in ATB included selection (3.3%), dosage (22%), frequency (3%), and duration (32%). There is a compelling need to create antimicrobial stewardship (AMS) programs to improve antibiotic use due to the high number of prescriptions in the ED deemed as inappropriate. This will help to prevent unwanted consequences on the patients and the community associated with antibiotic use.
Collapse
|
11
|
Smedemark SA, Aabenhus R, Llor C, Fournaise A, Olsen O, Jørgensen KJ. Biomarkers as point-of-care tests to guide prescription of antibiotics in people with acute respiratory infections in primary care. Cochrane Database Syst Rev 2022; 10:CD010130. [PMID: 36250577 PMCID: PMC9575154 DOI: 10.1002/14651858.cd010130.pub3] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Acute respiratory infections (ARIs) are by far the most common reason for prescribing an antibiotic in primary care, even though the majority of ARIs are of viral or non-severe bacterial aetiology. It follows that in many cases antibiotic use will not be beneficial to a patient's recovery but may expose them to potential side effects. Furthermore, limiting unnecessary antibiotic use is a key factor in controlling antibiotic resistance. One strategy to reduce antibiotic use in primary care is point-of-care biomarkers. A point-of-care biomarker (test) of inflammation identifies part of the acute phase response to tissue injury regardless of the aetiology (infection, trauma, or inflammation) and may be used as a surrogate marker of infection, potentially assisting the physician in the clinical decision whether to use an antibiotic to treat ARIs. Biomarkers may guide antibiotic prescription by ruling out a serious bacterial infection and help identify patients in whom no benefit from antibiotic treatment can be anticipated. This is an update of a Cochrane Review first published in 2014. OBJECTIVES To assess the benefits and harms of point-of-care biomarker tests of inflammation to guide antibiotic treatment in people presenting with symptoms of acute respiratory infections in primary care settings regardless of patient age. SEARCH METHODS We searched CENTRAL (2022, Issue 6), MEDLINE (1946 to 14 June 2022), Embase (1974 to 14 June 2022), CINAHL (1981 to 14 June 2022), Web of Science (1955 to 14 June 2022), and LILACS (1982 to 14 June 2022). We also searched three trial registries (10 December 2021) for completed and ongoing trials. SELECTION CRITERIA We included randomised controlled trials (RCTs) in primary care patients with ARIs that compared the use of point-of-care biomarkers with standard care. We included trials that randomised individual participants, as well as trials that randomised clusters of patients (cluster-RCTs). DATA COLLECTION AND ANALYSIS Two review authors independently extracted data on the following primary outcomes: number of participants given an antibiotic prescription at index consultation and within 28 days follow-up; participant recovery within seven days follow-up; and total mortality within 28 days follow-up. We assessed risk of bias using the Cochrane risk of bias tool and the certainty of the evidence using GRADE. We used random-effects meta-analyses when feasible. We further analysed results with considerable heterogeneity in prespecified subgroups of individual and cluster-RCTs. MAIN RESULTS We included seven new trials in this update, for a total of 13 included trials. Twelve trials (10,218 participants in total, 2335 of which were children) evaluated a C-reactive protein point-of-care test, and one trial (317 adult participants) evaluated a procalcitonin point-of-care test. The studies were conducted in Europe, Russia, and Asia. Overall, the included trials had a low or unclear risk of bias. However all studies were open-labelled, thereby introducing high risk of bias due to lack of blinding. The use of C-reactive protein point-of-care tests to guide antibiotic prescription likely reduces the number of participants given an antibiotic prescription, from 516 prescriptions of antibiotics per 1000 participants in the control group to 397 prescriptions of antibiotics per 1000 participants in the intervention group (risk ratio (RR) 0.77, 95% confidence interval (CI) 0.69 to 0.86; 12 trials, 10,218 participants; I² = 79%; moderate-certainty evidence). Overall, use of C-reactive protein tests also reduce the number of participants given an antibiotic prescription within 28 days follow-up (664 prescriptions of antibiotics per 1000 participants in the control group versus 538 prescriptions of antibiotics per 1000 participants in the intervention group) (RR 0.81, 95% CI 0.76 to 0.86; 7 trials, 5091 participants; I² = 29; high-certainty evidence). The prescription of antibiotics as guided by C-reactive protein tests likely does not reduce the number of participants recovered, within seven or 28 days follow-up (567 participants recovered within seven days follow-up per 1000 participants in the control group versus 584 participants recovered within seven days follow-up per 1000 participants in the intervention group) (recovery within seven days follow-up: RR 1.03, 95% CI 0.96 to 1.12; I² = 0%; moderate-certainty evidence) (recovery within 28 days follow-up: RR 1.02, 95% CI 0.79 to 1.32; I² = 0%; moderate-certainty evidence). The use of C-reactive protein tests may not increase total mortality within 28 days follow-up, from 1 death per 1000 participants in the control group to 0 deaths per 1000 participants in the intervention group (RR 0.53, 95% CI 0.10 to 2.92; I² = 0%; low-certainty evidence). We are uncertain as to whether procalcitonin affects any of the primary or secondary outcomes because there were few participants, thereby limiting the certainty of evidence. We assessed the certainty of the evidence as moderate to high according to GRADE for the primary outcomes for C-reactive protein test, except for mortality, as there were very few deaths, thereby limiting the certainty of the evidence. AUTHORS' CONCLUSIONS The use of C-reactive protein point-of-care tests as an adjunct to standard care likely reduces the number of participants given an antibiotic prescription in primary care patients who present with symptoms of acute respiratory infection. The use of C-reactive protein point-of-care tests likely does not affect recovery rates. It is unlikely that further research will substantially change our conclusion regarding the reduction in number of participants given an antibiotic prescription, although the size of the estimated effect may change. The use of C-reactive protein point-of-care tests may not increase mortality within 28 days follow-up, but there were very few events. Studies that recorded deaths and hospital admissions were performed in children from low- and middle-income countries and older adults with comorbidities. Future studies should focus on children, immunocompromised individuals, and people aged 80 years and above with comorbidities. More studies evaluating procalcitonin and potential new biomarkers as point-of-care tests used in primary care to guide antibiotic prescription are needed. Furthermore, studies are needed to validate C-reactive protein decision algorithms, with a specific focus on potential age group differences.
Collapse
Affiliation(s)
- Siri Aas Smedemark
- Department of Geriatric Medicine, Odense University Hospital, Odense, Denmark
- Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Rune Aabenhus
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Carl Llor
- University Institute in Primary Care Research Jordi Gol, Via Roma Health Centre, Barcelona, Spain
- Research Unit of General Practice, Department of Public Health, General Practice, University of Southern Denmark, Odense, Denmark
| | - Anders Fournaise
- Department of Geriatric Medicine, Odense University Hospital, Odense, Denmark
- Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Cross-sectoral Collaboration, Region of Southern Denmark, Vejle, Denmark
- Epidemiology, Biostatistics and Biodemography, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Ole Olsen
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | | |
Collapse
|
12
|
Löffler C, Buuck T, Iwen J, Schulz M, Zapf A, Kropp P, Wollny A, Krause L, Müller B, Ozga AK, Goldschmidt E, Altiner A. Promoting rational antibiotic therapy among high antibiotic prescribers in German primary care-study protocol of the ElektRA 4-arm cluster-randomized controlled trial. Implement Sci 2022; 17:69. [PMID: 36195897 PMCID: PMC9530431 DOI: 10.1186/s13012-022-01241-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 09/21/2022] [Indexed: 11/15/2022] Open
Abstract
Background The rational use of antibiotics is of great importance in health care. In primary care, acute respiratory infections are the most common cause of inappropriate antibiotic prescribing. Since existing studies aiming to optimize antibiotic use are usually based on the voluntary participation of physicians, general practitioners (GPs) with inappropriate prescribing behavior are underrepresented. For the first time in Germany, the ElektRA study will assess and compare the effects of three interventions on antibiotic prescribing rates for respiratory and urinary tract infections among high prescribers in primary care. Method ElektRA is a 4-arm cluster-randomized controlled trial among German GPs in nine regional Associations of Statutory Health Insurance Physicians. On their behalf, the Central Research Institute of Ambulatory Health Care in Germany (Zi) analyses all outpatient claims and prescription data. Based on this database, high antibiotic prescribing GPs are identified and randomized into four groups: a control group (N=2000) and three intervention arms. We test social norm feedback on antibiotic prescribing (N=2000), social norm feedback plus online training on rational prescribing practice and communication strategies (N=2000), and social norm feedback plus online peer-moderated training on rational antibiotic prescribing, communication strategies, and sustainable behavior change (N=1250). The primary outcome is the overall rate of antibiotic prescriptions. Outcomes are measured before intervention (T0, October 2020–September 2022) and over a period of 15 months (T1, October 2022 to December 2023) after randomization. Discussion The aim of the study is to implement individualized, low-threshold interventions to reduce antibiotic prescribing among high prescribers in primary care. If successful, a change in behavior among otherwise difficult-to-reach high prescribers will directly improve patient care. The increase in quality of care will ideally be achieved both in terms of the quantity of antibiotics used as well as the kind of substances prescribed. Also, if effective strategies for high prescribers are identified through this study, they can be applied not only to the antibiotics addressed in this study, but also to other areas of prescription management. Trial registration Current Controlled Trials ISRCTN95468513. Supplementary Information The online version contains supplementary material available at 10.1186/s13012-022-01241-4.
Collapse
Affiliation(s)
- Christin Löffler
- Institute of General Practice, Rostock University Medical Center, Postbox 100888, 18055, Rostock, Germany.
| | - Theresa Buuck
- Institute of General Practice, Rostock University Medical Center, Postbox 100888, 18055, Rostock, Germany
| | - Julia Iwen
- Association of Substitute Health Funds (Vdek) e.V, Berlin, Germany
| | - Maike Schulz
- Central Research Institute of Ambulatory Health Care in Germany (Zi), Berlin, Germany
| | - Antonia Zapf
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Kropp
- Institute of Medical Psychology and Medical Sociology, Rostock University Medical Center, Rostock, Germany
| | - Anja Wollny
- Institute of General Practice, Rostock University Medical Center, Postbox 100888, 18055, Rostock, Germany
| | - Linda Krause
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Britta Müller
- Institute of Medical Psychology and Medical Sociology, Rostock University Medical Center, Rostock, Germany
| | - Ann-Katrin Ozga
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Attila Altiner
- Institute of General Practice, Rostock University Medical Center, Postbox 100888, 18055, Rostock, Germany
| |
Collapse
|
13
|
Educational Interventions to Reduce Prescription and Dispensing of Antibiotics in Primary Care: A Systematic Review of Economic Impact. Antibiotics (Basel) 2022; 11:antibiotics11091186. [PMID: 36139965 PMCID: PMC9495011 DOI: 10.3390/antibiotics11091186] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 08/19/2022] [Accepted: 08/29/2022] [Indexed: 11/16/2022] Open
Abstract
Antibiotic resistance remains a crucial global public health problem with excessive and inappropriate antibiotic use representing an important driver of this issue. Strategies to improve antibiotic prescription and dispensing are required in primary health care settings. The main purpose of this review is to identify and synthesize available evidence on the economic impact of educational interventions to reduce prescription and dispensing of antibiotics among primary health care professionals. Information about the clinical impact resulting from the implementation of interventions was also gathered. PubMed, Scopus, Web of Science and EMBASE were the scientific databases used to search and identify relevant studies. Of the thirty-three selected articles, most consisted of a simple intervention, such as a guideline implementation, while the others involved multifaceted interventions, and differed regarding study populations, designs and settings. Main findings were grouped either into clinical or cost outcomes. Twenty of the thirty-three articles included studies reporting a reduction in outcome costs, namely in antibiotic cost and associated prescription costs, in part due to an overall improvement in the appropriateness of antibiotic use. The findings of this study show that the implementation of educational interventions is a cost-effective strategy to reduce antibiotic prescription and dispensing among primary healthcare providers.
Collapse
|
14
|
Ashiru-Oredope D, Casale E, Harvey E, Umoh E, Vasandani S, Reilly J, Hopkins S. Knowledge and Attitudes about Antibiotics and Antibiotic Resistance of 2404 UK Healthcare Workers. Antibiotics (Basel) 2022; 11:antibiotics11081133. [PMID: 36010002 PMCID: PMC9404832 DOI: 10.3390/antibiotics11081133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 08/02/2022] [Accepted: 08/05/2022] [Indexed: 11/19/2022] Open
Abstract
Background: Using the COM-B model as a framework, an EU-wide survey aimed to ascertain multidisciplinary healthcare workers’ (HCWs’) knowledge, attitudes and behaviours towards antibiotics, antibiotic use and antibiotic resistance. The UK findings are presented here. Methods: A 43-item questionnaire was developed through a two-round modified Delphi consensus process. The UK target quota was 1315 respondents. Results: In total, 2404 participants responded. The highest proportion were nursing and midwifery professionals (42%), pharmacists (23%) and medical doctors (18%). HCWs correctly answered that antibiotics are not effective against viruses (97%), they have associated side effects (97%), unnecessary use makes antibiotics ineffective (97%) and healthy people can carry antibiotic-resistant bacteria (90%). However, fewer than 80% correctly answered that using antibiotics increases a patient’s risk of antimicrobial resistant infection or that resistant bacteria can spread from person to person. Whilst the majority of HCWs (81%) agreed there is a connection between their antibiotic prescribing behaviour and the spread of antibiotic-resistant bacteria, only 64% felt that they have a key role in controlling antibiotic resistance. The top three barriers to providing advice or resources were lack of resources (19%), insufficient time (11%) and the patient being uninterested in the information (7%). Approximately 35% of UK respondents who were prescribers prescribed an antibiotic at least once in the previous week to responding to the survey due to a fear of patient deterioration or complications. Conclusion: These findings highlight that a multifaceted approach to tackling the barriers to prudent antibiotic use in the UK is required and provides evidence for guiding targeted policy, intervention development and future research. Education and training should focus on patient communication, information on spreading resistant bacteria and increased risk for individuals.
Collapse
Affiliation(s)
- Diane Ashiru-Oredope
- HCAI, Fungal, AMR, AMU & Sepsis Division, United Kingdom Health Security Agency, London SW1P 3JR, UK
- Correspondence:
| | - Ella Casale
- HCAI, Fungal, AMR, AMU & Sepsis Division, United Kingdom Health Security Agency, London SW1P 3JR, UK
| | - Eleanor Harvey
- HCAI, Fungal, AMR, AMU & Sepsis Division, United Kingdom Health Security Agency, London SW1P 3JR, UK
| | - Eno Umoh
- HCAI, Fungal, AMR, AMU & Sepsis Division, United Kingdom Health Security Agency, London SW1P 3JR, UK
| | - Sagar Vasandani
- HCAI, Fungal, AMR, AMU & Sepsis Division, United Kingdom Health Security Agency, London SW1P 3JR, UK
| | - Jacqui Reilly
- NHS National Services Scotland, Edinburgh EH12 9EB, UK
- Department of Nursing and Community Health, Glasgow Caledonian University, Glasgow G4 0BA, UK
| | - Susan Hopkins
- HCAI, Fungal, AMR, AMU & Sepsis Division, United Kingdom Health Security Agency, London SW1P 3JR, UK
| |
Collapse
|
15
|
Amponsah OKO, Nagaraja SB, Ayisi-Boateng NK, Nair D, Muradyan K, Asense PS, Wusu-Ansah OK, Terry RF, Khogali M, Buabeng KO. High Levels of Outpatient Antibiotic Prescription at a District Hospital in Ghana: Results of a Cross Sectional Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:10286. [PMID: 36011917 PMCID: PMC9407799 DOI: 10.3390/ijerph191610286] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 08/13/2022] [Accepted: 08/16/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Monitoring of antibiotic prescription practices in hospitals is essential to assess and facilitate appropriate use. This is relevant to halt the progression of antimicrobial resistance. METHODS Assessment of antibiotic prescribing patterns and completeness of antibiotic prescriptions among out-patients in 2021 was conducted at the University Hospital of Kwame Nkrumah University of Science and Technology in the Ashanti region of Ghana. We reviewed electronic medical records (EMR) of 49,660 patients who had 110,280 encounters in the year. RESULTS The patient encounters yielded 350,149 prescriptions. Every month, 33-36% of patient encounters resulted in antibiotic prescription, higher than the World Health Organization's (WHO) recommended optimum of 27%. Almost half of the antibiotics prescribed belonged to WHO's Watch group. Amoxicillin-clavulanic acid (50%), azithromycin (29%), ciprofloxacin (28%), metronidazole (21%), and cefuroxime (20%) were the most prescribed antibiotics. Antibiotic prescribing parameters (indication, name of drug, duration, dose, route, and frequency) were documented in almost all prescriptions. CONCLUSIONS Extending antimicrobial stewardship to the out-patient settings by developing standard treatment guidelines, an out-patient specific drug formulary, and antibiograms can promote rational antibiotic use at the hospital. The EMR system of the hospital is a valuable tool for monitoring prescriptions that can be leveraged for future audits.
Collapse
Affiliation(s)
- Obed Kwabena Offe Amponsah
- Department of Pharmacy Practice, Kwame Nkrumah University of Science and Technology, Kumasi 00233, Ghana
| | | | - Nana Kwame Ayisi-Boateng
- Department of Medicine, Kwame Nkrumah University of Science and Technology, Kumasi 00233, Ghana
- University Hospital, Kwame Nkrumah University of Science and Technology, Kumasi 00233, Ghana
| | - Divya Nair
- International Union against TB and Lung Disease (The Union), 75006 Paris, France
| | - Karlos Muradyan
- Tuberculosis Research and Prevention Center, Yerevan 0014, Armenia
| | - Phanuel Seli Asense
- University Hospital, Kwame Nkrumah University of Science and Technology, Kumasi 00233, Ghana
| | - Osei Kwaku Wusu-Ansah
- University Hospital, Kwame Nkrumah University of Science and Technology, Kumasi 00233, Ghana
| | - Robert Fraser Terry
- Special Programme for Research and Training in Tropical Diseases (TDR), World Health Organisation, 1211 Geneva, Switzerland
| | - Mohammed Khogali
- Special Programme for Research and Training in Tropical Diseases (TDR), World Health Organisation, 1211 Geneva, Switzerland
| | - Kwame Ohene Buabeng
- Department of Pharmacy Practice, Kwame Nkrumah University of Science and Technology, Kumasi 00233, Ghana
| |
Collapse
|
16
|
Nedved A, Lee BR, Hamner M, Wirtz A, Burns A, El Feghaly RE. Impact of an Antibiotic Stewardship Program on Antibiotic Choice, Dosing, and Duration in Pediatric Urgent Cares. Am J Infect Control 2022; 51:520-526. [PMID: 35940256 DOI: 10.1016/j.ajic.2022.07.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 07/28/2022] [Accepted: 07/29/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Many antimicrobial stewardship programs (ASPs) focus on decreasing unnecessary antibiotics. We describe the impact of an outpatient ASP on choice, dose, and duration of antibiotics when used for common infections in pediatric urgent care (PUC) centers. METHODS We reviewed encounters at 4 PUC centers within our organization for patients 6 months to 18 years old with acute otitis media, group A streptococcal pharyngitis, community-acquired pneumonia, urinary tract infection, and skin and soft tissue infections who received systemic antibiotics. We determined appropriate antibiotic choice, dose, and duration for each diagnosis. Pearson's χ² test compared appropriate prescribing before ASP implementation (July 2017-July 2018) and postimplementation (August 2018-December 2020). Control charts trended improvement over time. RESULTS Our study included 35,917 encounters. The percentage of prescriptions with the recommend agent at the appropriate dose and duration increased from a mean of 32.7% to 52.4%. The center lines for appropriate agent, dose, and duration all underwent upward shifts. The most substantial changes were seen in antibiotic duration (63.2%-80.5%), and appropriate dose (64.6%-77%). CONCLUSIONS Implementation of an outpatient ASP improved prescribing patterns for choosing the appropriate agent, duration, and dose for many common infections in our PUCs.
Collapse
Affiliation(s)
- Amanda Nedved
- Department of Pediatrics, Division of Urgent Care, Children's Mercy Kansas City, Kansas City, MO; University of Missouri-Kansas City, Kansas City, MO
| | - Brian R Lee
- University of Missouri-Kansas City, Kansas City, MO; Department of Pediatrics, Division of Health Services and Outcomes Research, Children's Mercy Kansas City, Kansas City, MO
| | - Megan Hamner
- Department of Pediatrics, Division of Infectious Diseases, Children's Mercy Kansas City, Kansas City, MO
| | - Ann Wirtz
- University of Missouri-Kansas City, Kansas City, MO; Department of Pediatrics, Division of Pharmacy, Children's Mercy Kansas City, Kansas City, MO
| | - Alaina Burns
- University of Missouri-Kansas City, Kansas City, MO; Department of Pediatrics, Division of Pharmacy, Children's Mercy Kansas City, Kansas City, MO
| | - Rana E El Feghaly
- University of Missouri-Kansas City, Kansas City, MO; Department of Pediatrics, Division of Infectious Diseases, Children's Mercy Kansas City, Kansas City, MO.
| |
Collapse
|
17
|
Liu E, Linder KE, Kuti JL. Antimicrobial Stewardship at Transitions of Care to Outpatient Settings: Synopsis and Strategies. Antibiotics (Basel) 2022; 11:antibiotics11081027. [PMID: 36009896 PMCID: PMC9405265 DOI: 10.3390/antibiotics11081027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 07/19/2022] [Accepted: 07/20/2022] [Indexed: 02/01/2023] Open
Abstract
Inappropriate antibiotic use and associated consequences, including pathogen resistance and Clostridioides difficile infection, continue to serve as significant threats in the United States, with increasing incidence in the community setting. While much attention has been granted towards antimicrobial stewardship in acute care settings, the transition to the outpatient setting represents a significant yet overlooked area to target optimized antimicrobial utilization. In this article, we highlight notable areas for improved practices and present an interventional approach to stewardship tactics with a framework of disease, drug, dose, and duration. In doing so, we review current evidence regarding stewardship strategies at transitional settings, including diagnostic guidance, technological clinical support, and behavioral and educational approaches for both providers and patients.
Collapse
Affiliation(s)
- Elaine Liu
- Department of Pharmacy Services, Hartford Healthcare, Hartford, CT 06106, USA; (E.L.); (K.E.L.)
| | - Kristin E. Linder
- Department of Pharmacy Services, Hartford Healthcare, Hartford, CT 06106, USA; (E.L.); (K.E.L.)
| | - Joseph L. Kuti
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT 06106, USA
- Correspondence:
| |
Collapse
|
18
|
Tagashira Y. Effect of discontinuing ongoing education and postprescription feedback on antimicrobial prescriptions at discharge from the emergency department. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2022; 2:e124. [PMID: 36483425 PMCID: PMC9726547 DOI: 10.1017/ash.2022.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 01/12/2022] [Indexed: 06/17/2023]
Abstract
Multifaceted intervention is preferrable as an ASP strategy in the emergency department (ED). I assessed the effect of discontinuing multifaceted intervention for antimicrobial prescriptions at discharge in the emergency department. The proportion of appropriate prescriptions decreased quickly after discontinuation. Continuous commitment to appropriate antimicrobial prescriptions is needed for effective antimicrobial stewardship.
Collapse
Affiliation(s)
- Yasuaki Tagashira
- Department of Infectious Diseases, Tokyo Medical and Dental University Graduate School of Medical and Dental Sciences, TokyoJapan
- Department of Infectious Diseases, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| |
Collapse
|
19
|
Chater AM, Hannah Family, Abraao LM, Burnett E, Castro-Sanchez E, Du Toit B, Gallagher R, Gotterson F, Manias E, Mcewen J, Moralez de Figueiredo R, Nathan M, Ness V, Olans R, Padoveze MC, Courtenay M. Influences on nurses' engagement in antimicrobial stewardship behaviours: A multi-country survey using the Theoretical Domains Framework. J Hosp Infect 2022; 129:171-180. [PMID: 35843415 DOI: 10.1016/j.jhin.2022.07.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 06/20/2022] [Accepted: 07/04/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Antimicrobial resistance (AMR) is significantly affected by inappropriate antibiotic use, and is one of the greatest threats to human health. Antimicrobial stewardship (AMS) is a programme of actions promoting responsible antimicrobial use, and is essential for limiting AMR. Nurses have an important role to play in this context. AIM This study investigated the determinants of nurse AMS behaviours and the impact of past training. METHOD A cross-sectional multi-country survey design with mixed methods was employed. Participants were 262 nurses (223 female; mean age = 44.45; SD = 10.77 years) from ten nationalities, with individual survey links sent via professional networks in 5 countries, alongside Twitter. Nine AMS behaviours and 14 behavioural determinants were quantitatively assessed using the Theoretical Domains Framework (TDF), and mapped to the COM-B (Capability, Opportunity, Motivation - Behaviour) model. Analysis identified differences between nurses with and without AMS training. The influence of COVID-19 on AMS behaviour was qualitatively investigated using free text data. FINDINGS Nurses performed all nine AMS behaviours, which were significantly higher (t(238) = -4.14, p < .001), by those who had training (M = 53.15; SD = 7.40) compared to those who had not (M = 48.30; SD = 10.75). Those with AMS training scored significantly higher in all of the TDF domains. The TDF was able to explain 27% of the variance in behaviour, with 'Skills' and 'Behavioural Regulation' (e.g. ability to self-monitor and plan), shown to be the most predictive of AMS actions. Both of these domains are situated in the Capability construct of COM-B, which can be enhanced with the intervention strategies of education and training. An increase in AMS behaviours was reported since COVID-19, regardless of previous training. Six core themes were linked to AMS: 1) Infection prevention and control, 2) Antimicrobials and antimicrobial resistance, 3) The diagnosis of infection and the use of antibiotics, 4) Antimicrobial prescribing practice, 5) Person-centred care, and 6) Interprofessional collaborative practice. CONCLUSION This research, has identified the significant benefit of nurse training on AMS behaviour, and its determinants. Those who had training, scored higher in all TDF determinants of behaviour, compared to those who had had no training, resulting in higher Capability, Opportunity and Motivation to perform AMS behaviours. AMS education and training should be offered to nurses to enhance these factors. Future research should consider the optimal level of training to optimise AMS behaviour, with a focus on developing skills and behavioural regulation.
Collapse
Affiliation(s)
- Angel Marie Chater
- Centre for Health, Wellbeing and Behaviour Change, University of Bedfordshire, Bedford, UK; Centre for Behaviour Change, University College London, UK.
| | - Hannah Family
- Bristol Medical School, Bristol University, Bristol, UK.
| | - Ligia Maria Abraao
- Americas Medical Serviçes, United Health Group, Sao Paulo State, Brazil.
| | - Emma Burnett
- Fatima College of Health Sciences, Abu Dhabi, United Arab Emirates.
| | | | - Briëtte Du Toit
- Infection Control Africa Network, Cape Town, Western Cape, South Africa.
| | | | - Fiona Gotterson
- National Centre for Antimicrobial Stewardship, The Peter Doherty Institute for Infections and Immunity, Dept of Medicine, The University of Melbourne, Melbourne, Australia.
| | - Elizabeth Manias
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Institute for Health Transformation, Deakin University, Burwood, Australia; The Royal Melbourne Hospital, Department of Medicine, The University of Melbourne, Melbourne, Australia.
| | | | - Rosely Moralez de Figueiredo
- Departamento de Enfermagem, Centro de Ciências Biológicas e da Saúde, Universidade Federal de São Carlos - UFSCar.
| | - Martina Nathan
- School of Healthcare Sciences, Cardiff University, Cardiff, UK.
| | - Val Ness
- Department of Nursing & Community Health/ School of Health & Life Sciences, Glasgow Caledonian University, Glasgow, UK.
| | - Rita Olans
- School of Nursing, MGH Institute of Health Professions, Boston, USA;.
| | | | - Molly Courtenay
- School of Healthcare Sciences, Cardiff University, Cardiff, UK.
| |
Collapse
|
20
|
Yigzaw KY, Chomutare T, Wynn R, Berntsen GKR, Bellika JG. A Privacy-Preserving Audit and Feedback System for the Antibiotic Prescribing of General Practitioners: Survey Study. JMIR Form Res 2022; 6:e31650. [PMID: 35830221 PMCID: PMC9330202 DOI: 10.2196/31650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 03/21/2022] [Accepted: 04/14/2022] [Indexed: 11/13/2022] Open
Abstract
Background Antibiotic resistance is a worldwide public health problem that is accelerated by the misuse and overuse of antibiotics. Studies have shown that audits and feedback enable clinicians to compare their personal clinical performance with that of their peers and are effective in reducing the inappropriate prescribing of antibiotics. However, privacy concerns make audits and feedback hard to implement in clinical settings. To solve this problem, we developed a privacy-preserving audit and feedback (A&F) system. Objective This study aims to evaluate a privacy-preserving A&F system in clinical settings. Methods A privacy-preserving A&F system was deployed at three primary care practices in Norway to generate feedback for 20 general practitioners (GPs) on their prescribing of antibiotics for selected respiratory tract infections. The GPs were asked to participate in a survey shortly after using the system. Results A total of 14 GPs responded to the questionnaire, representing a 70% (14/20) response rate. The participants were generally satisfied with the usefulness of the feedback and the comparisons with peers, as well as the protection of privacy. The majority of the GPs (9/14, 64%) valued the protection of their own privacy as well as that of their patients. Conclusions The system overcomes important privacy and scaling challenges that are commonly associated with the secondary use of electronic health record data and has the potential to improve antibiotic prescribing behavior; however, further study is required to assess its actual effect.
Collapse
Affiliation(s)
| | - Taridzo Chomutare
- Norwegian Centre for E-health Research, University Hospital of North Norway, Tromsø, Norway
| | - Rolf Wynn
- Institute of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
- Divison of Substance Use and Mental Health, University Hospital of North Norway, Tromsø, Norway
| | - Gro Karine Rosvold Berntsen
- Norwegian Centre for E-health Research, University Hospital of North Norway, Tromsø, Norway
- Department of Community Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - Johan Gustav Bellika
- Norwegian Centre for E-health Research, University Hospital of North Norway, Tromsø, Norway
- Institute of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| |
Collapse
|
21
|
Kanj SS, Ramirez P, Rodrigues C. Beyond the Pandemic: The Value of Antimicrobial Stewardship. Front Public Health 2022; 10:902835. [PMID: 35832270 PMCID: PMC9271661 DOI: 10.3389/fpubh.2022.902835] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 06/08/2022] [Indexed: 11/19/2022] Open
Affiliation(s)
- Souha S. Kanj
- Division of Infectious Diseases, American University of Beirut Medical Center, Beirut, Lebanon
- *Correspondence: Souha S. Kanj
| | - Paula Ramirez
- Critical Care Department, Hospital Universitari I Politècnic La Fe, Valencia, Spain
| | - Camilla Rodrigues
- Department of Microbiology, P. D. Hinduja Hospital and Medical Research Centre, Mumbai, India
| |
Collapse
|
22
|
Zheng K, Xie Y, Dan L, Mao M, Chen J, Li R, Wang X, Hesketh T. Effectiveness of Educational Interventions for Health Workers on Antibiotic Prescribing in Outpatient Settings in China: A Systematic Review and Meta-Analysis. Antibiotics (Basel) 2022; 11:antibiotics11060791. [PMID: 35740197 PMCID: PMC9220158 DOI: 10.3390/antibiotics11060791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 05/30/2022] [Accepted: 06/07/2022] [Indexed: 02/01/2023] Open
Abstract
Educational interventions are considered an important component of antibiotic stewardship, but their effect has not been systematically evaluated in outpatient settings in China. This research aims to evaluate the effectiveness of educational interventions for health workers on antibiotic prescribing rates in Chinese outpatient settings. Eight databases were searched for relevant randomized clinical trials, non-randomized trials, controlled before–after studies and interrupted time-series studies from January 2001 to July 2021. A total of 16 studies were included in the systematic review and 12 in the meta-analysis. The results showed that educational interventions overall reduced the antibiotic prescription rate significantly (relative risk, RR 0.72, 95% confidence interval, CI 0.61 to 0.84). Subgroup analysis demonstrated that certain features of education interventions had a significant effect on antibiotic prescription rate reduction: (1) combined with compulsory administrative regulations (RR With: 0.65 vs. Without: 0.78); (2) combined with financial incentives (RR With: 0.51 vs. Without: 0.77). Educational interventions can also significantly reduce antibiotic injection rates (RR 0.83, 95% CI 0.74 to 0.94) and the inappropriate use of antibiotics (RR 0.61, 95% CI 0.51 to 0.73). The limited number of high-quality studies limits the validity and reliability of the results. More high-quality educational interventions targeting the reduction of antibiotic prescribing rates are needed.
Collapse
Affiliation(s)
- Kunhua Zheng
- People’s Hospital of Kaihua, Quzhou 324300, China; (K.Z.); (M.M.)
| | - Ying Xie
- Center for Global Health, Zhejiang University School of Medicine, Hangzhou 310000, China; (Y.X.); (L.D.); (J.C.); (R.L.); (T.H.)
| | - Lintao Dan
- Center for Global Health, Zhejiang University School of Medicine, Hangzhou 310000, China; (Y.X.); (L.D.); (J.C.); (R.L.); (T.H.)
| | - Meixian Mao
- People’s Hospital of Kaihua, Quzhou 324300, China; (K.Z.); (M.M.)
| | - Jie Chen
- Center for Global Health, Zhejiang University School of Medicine, Hangzhou 310000, China; (Y.X.); (L.D.); (J.C.); (R.L.); (T.H.)
| | - Ran Li
- Center for Global Health, Zhejiang University School of Medicine, Hangzhou 310000, China; (Y.X.); (L.D.); (J.C.); (R.L.); (T.H.)
- Institute for Global Health, University College London, London WC1E 6BT, UK
| | - Xuanding Wang
- Department of Antimicrobial Stewardship, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310000, China
- Correspondence:
| | - Therese Hesketh
- Center for Global Health, Zhejiang University School of Medicine, Hangzhou 310000, China; (Y.X.); (L.D.); (J.C.); (R.L.); (T.H.)
- Institute for Global Health, University College London, London WC1E 6BT, UK
| |
Collapse
|
23
|
General Practitioners’, Pharmacists’ and Parents’ Views on Antibiotic Use and Resistance in Malta: An Exploratory Qualitative Study. Antibiotics (Basel) 2022; 11:antibiotics11050661. [PMID: 35625305 PMCID: PMC9137633 DOI: 10.3390/antibiotics11050661] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 05/05/2022] [Accepted: 05/12/2022] [Indexed: 02/04/2023] Open
Abstract
Background: Antibiotic resistance (ABR) remains a global health threat that requires urgent action. Antibiotic use is a key driver of ABR and is particularly problematic in the outpatient setting. General practitioners (GPs), the public, and pharmacists therefore play an important role in safeguarding antibiotics. In this study, we aimed to gain a better understanding of the antibiotic prescribing-use-dispensation dynamic in Malta from the perspective of GPs, pharmacists, and parents; Methods: we conducted 8 focus groups with 8 GPs, 24 pharmacists, and 18 parents between 2014 and 2016. Data were analysed using inductive and deductive content analysis; Results: Awareness on antibiotic overuse and ABR was generally high among interviewees although antibiotic use was thought to be improving. Despite this, some believed that antibiotic demand, non-compliance, and over-the-counter dispensing are still a problem. Nevertheless, interviewees believed that the public is more accepting of alternative strategies, such as delayed antibiotic prescription. Both GPs and pharmacists were enthusiastic about their roles as patient educators in raising knowledge and awareness in this context; Conclusions: While antibiotic use and misuse, and knowledge and awareness, were perceived to have improved in Malta, our study suggests that even though stakeholders indicated willingness to drive change, there is still much room for improvement.
Collapse
|
24
|
Lu J, Liu C, Wang D, Zhang X. Influence of Work Values on the Prescribing Behavioral Intentions Regarding Antibiotic Use Among Primary Physicians in Hubei, China. Front Public Health 2022; 10:830181. [PMID: 35646752 PMCID: PMC9136237 DOI: 10.3389/fpubh.2022.830181] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 03/31/2022] [Indexed: 11/16/2022] Open
Abstract
Objective Primary physicians have been an important cause of global antibiotic resistance. The aim of this study is to identify the influence of primary physicians' work values on prescribing behavioral intentions regarding antibiotic use (behavioral intentions). Methods A total of 656 primary physicians' work values and behavioral intentions were collected by a stratified cluster sampling from 67 primary care facilities in Hubei Province of China. Work values included 5 dimensions, namely intrinsic values, extrinsic values, reward values, social values and altruistic values. Behavioral intentions included 2 dimensions of the intentions to reduce antibiotic prescriptions and the intentions to prescribe antibiotics. A Likert five-point scale was used and higher scores meant greater intentions to prescribe antibiotics. A hierarchical multiple regression analysis was employed to model the influence of work values on behavioral intentions. Results Primary physicians' behavioral intention was 2.01 averagely. Intrinsic values negatively influenced overall intentions to prescribe more antibiotics (β = −0.098, P = 0.010). Whereas lower social values perception (β = 0.248, P < 0.001), less pursuit of reward values (β = 0.194, P < 0.001), and less emphasis on altruistic values (β = 0.180, P < 0.001) positively influenced lower overall intentions to prescribe antibiotic prescriptions. Besides, extrinsic values were not found influencing the behavioral intentions (β = 0.001, P = 0.961). Conclusions Primary physicians' work values influenced their behavioral intentions regarding antibiotic use. Training and education of work values may be an entry point for intervention on improving antibiotic prescribing.
Collapse
Affiliation(s)
- Junyu Lu
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chenxi Liu
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Dan Wang
- School of Management, Hubei University of Chinese Medicine, Wuhan, China
| | - Xinping Zhang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- *Correspondence: Xinping Zhang ;
| |
Collapse
|
25
|
Wu S, Tannous E, Haldane V, Ellen ME, Wei X. Barriers and facilitators of implementing interventions to improve appropriate antibiotic use in low- and middle-income countries: a systematic review based on the Consolidated Framework for Implementation Research. Implement Sci 2022; 17:30. [PMID: 35550169 PMCID: PMC9096759 DOI: 10.1186/s13012-022-01209-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 04/30/2022] [Indexed: 11/10/2022] Open
Abstract
Background Behavior change interventions that aim to improve rational antibiotic use in prescribers and users have been widely conducted in both high- and LMICs. However, currently, no review has systematically examined challenges unique to LMICs and offered insights into the underlying contextual factors that influence these interventions. We adopted an implementation research perspective to systematically synthesize the implementation barriers and facilitators in LMICs. Methods We conducted literature searches in five electronic databases and identified studies that involved the implementation of behavior change interventions to improve appropriate antibiotic use in prescribers and users in LMICs and reported implementation barriers and facilitators. Behavior change interventions were defined using the behavior change wheel, and the coding and synthesis of barriers and facilitators were guided by the Consolidated Framework for Implementation Research (CFIR). Results We identified 52 eligible studies, with the majority targeting prescribers practicing at tertiary facilities (N=39, 75%). The most commonly reported factors influencing implementation were found in the inner setting domain of the CFIR framework, particularly related to constraints in resources and the infrastructure of the facilities where interventions were implemented. Barriers related to the external policy environment (e.g., lack of national initiatives and policies on antibiotic use), and individual characteristics of target populations (e.g., reluctance to change prescribing behaviors) were also common, as well as facilitators related to intervention characteristics (e.g., embedding interventions in routine practice) and process (e.g., stakeholder engagement). We also provided insights into the interrelationships between these factors and the underlying causes contributing to the implementation challenges in LMICs. Conclusion We presented a comprehensive overview of the barriers and facilitators of implementing behavior change interventions to promote rational antibiotic use in LMICs. Our findings suggest that facilitating the implementation of interventions to improve rational antibiotic use needs comprehensive efforts to address challenges at policy, organizational, and implementation levels. Specific strategies include (1) strengthening political commitment to prompt mobilization of domestic resources and formulation of a sustainable national strategy on AMR, (2) improving the infrastructure of health facilities that allow prescribers to make evidence-based clinical decisions, and (3) engaging local stakeholders to improve their buy-in and facilitate contextualizing interventions. Trial registration PROSPERO: CRD42021252715. Supplementary Information The online version contains supplementary material available at 10.1186/s13012-022-01209-4.
Collapse
Affiliation(s)
- Shishi Wu
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Elias Tannous
- Faculty of Health Sciences, Department of Clinical Biochemistry and Pharmacology, Ben Gurion University of the Negev, Beer-Sheva, Israel.,Pharmacy services, Hillel Yaffe Medical Center, Hadera, Israel
| | - Victoria Haldane
- Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Moriah E Ellen
- Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.,Department of Health Policy and Management, Guilford Glazer Faculty of Business and Management and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Xiaolin Wei
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada. .,Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.
| |
Collapse
|
26
|
Taylor MG, Palazzi DL. Antimicrobial Stewardship in the Pediatric Primary Care Setting. Pediatr Ann 2022; 51:e196-e201. [PMID: 35575544 DOI: 10.3928/19382359-20220315-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Antibiotics are the most commonly prescribed medications in the pediatric outpatient setting, yet 30% to 50% of these prescriptions are deemed to be unnecessary. Outpatient antimicrobial stewardship is the concerted effort to monitor and improve antibiotic use in the community setting. The best methods of conducting antimicrobial stewardship in the outpatient setting are currently unknown, and an individualized approach is likely needed. In this review, we discuss the importance of, resources for, and research supporting outpatient antimicrobial stewardship and review ways an individual pediatric provider can further steward efforts. [Pediatr Ann. 2022;51(5):e196-e201.].
Collapse
|
27
|
Martínez-González NA, Plate A, Jäger L, Senn O, Neuner-Jehle S. The Role of Point-of-Care C-Reactive Protein Testing in Antibiotic Prescribing for Respiratory Tract Infections: A Survey among Swiss General Practitioners. Antibiotics (Basel) 2022; 11:antibiotics11050543. [PMID: 35625187 PMCID: PMC9137646 DOI: 10.3390/antibiotics11050543] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 04/13/2022] [Accepted: 04/14/2022] [Indexed: 02/05/2023] Open
Abstract
Understanding the decision-making strategies of general practitioners (GPs) could help reduce suboptimal antibiotic prescribing. Respiratory tract infections (RTIs) are the most common reason for inappropriate antibiotic prescribing in primary care, a key driver of antibiotic resistance (ABR). We conducted a nationwide prospective web-based survey to explore: (1) The role of C-reactive protein (CRP) point-of-care testing (POCT) on antibiotic prescribing decision-making for RTIs using case vignettes; and (2) the knowledge, attitudes and barriers/facilitators of antibiotic prescribing using deductive analysis. Most GPs (92–98%) selected CRP-POCT alone or combined with other diagnostics. GPs would use lower CRP cut-offs to guide prescribing for (more) severe RTIs than for uncomplicated RTIs. Intermediate CRP ranges were significantly wider for uncomplicated than for (more) severe RTIs (p = 0.001). Amoxicillin/clavulanic acid was the most frequently recommended antibiotic across all RTI case scenarios (65–87%). Faced with intermediate CRP results, GPs preferred 3–5-day follow-up to delayed prescribing or other clinical approaches. Patient pressure, diagnostic uncertainty, fear of complications and lack of ABR understanding were the most GP-reported barriers to appropriate antibiotic prescribing. Stewardship interventions considering CRP-POCT and the barriers and facilitators to appropriate prescribing could guide antibiotic prescribing decisions at the point of care.
Collapse
Affiliation(s)
- Nahara Anani Martínez-González
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (A.P.); (L.J.); (O.S.); (S.N.-J.)
- Department of Health Sciences and Medicine, University of Lucerne, Frohburgstrasse 3, CH-6002 Lucerne, Switzerland
- Correspondence: or
| | - Andreas Plate
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (A.P.); (L.J.); (O.S.); (S.N.-J.)
| | - Levy Jäger
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (A.P.); (L.J.); (O.S.); (S.N.-J.)
| | - Oliver Senn
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (A.P.); (L.J.); (O.S.); (S.N.-J.)
| | - Stefan Neuner-Jehle
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland; (A.P.); (L.J.); (O.S.); (S.N.-J.)
| |
Collapse
|
28
|
Clinical Decision Support Systems for Antibiotic Prescribing: An Inventory of Current French Language Tools. Antibiotics (Basel) 2022; 11:antibiotics11030384. [PMID: 35326847 PMCID: PMC8944435 DOI: 10.3390/antibiotics11030384] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/08/2022] [Accepted: 03/10/2022] [Indexed: 02/04/2023] Open
Abstract
Clinical decision support systems (CDSSs) are increasingly being used by clinicians to support antibiotic decision making in infection management. However, coexisting CDSSs often target different types of physicians, infectious situations, and patient profiles. The objective of this study was to perform an up-to-date inventory of French language CDSSs currently used in community and hospital settings for antimicrobial prescribing and to describe their main characteristics. A literature search, a search among smartphone application stores, and an open discussion with antimicrobial stewardship (AMS) experts were conducted in order to identify available French language CDSSs. Any clinical decision support tool that provides a personalized recommendation based on a clinical situation and/or a patient was included. Eleven CDSSs were identified through the search strategy. Of the 11 CDSSs, only 2 had been the subject of published studies, while 9 CDSSs were identified through smartphone application stores and expert knowledge. The majority of CDSSs were available free of charge (n = 8/11, 73%). Most CDSSs were accessible via smartphone applications (n = 9/11, 82%) and online websites (n = 8/11, 73%). Recommendations for antibiotic prescribing in urinary tract infections, upper and lower respiratory tract infections, and digestive tract infections were provided by over 90% of the CDSSs. More than 90% of the CDSSs displayed recommendations for antibiotic selection, prioritization, dosage, duration, route of administration, and alternative antibiotics in case of allergy. Information about antibiotic side effects, prescription recommendations for specific patient profiles and adaptation to local epidemiology were often missing or incomplete. There is a significant but heterogeneous offer for antibiotic prescribing decision support in French language. Standardized evaluation of these systems is needed to assess their impact on antimicrobial prescribing and antimicrobial resistance.
Collapse
|
29
|
Arsenault C, Rowe SY, Ross-Degnan D, Peters DH, Roder-DeWan S, Kruk ME, Rowe AK. How does the effectiveness of strategies to improve healthcare provider practices in low-income and middle-income countries change after implementation? Secondary analysis of a systematic review. BMJ Qual Saf 2022; 31:123-133. [PMID: 34006598 PMCID: PMC8784997 DOI: 10.1136/bmjqs-2020-011717] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 03/22/2021] [Accepted: 04/29/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND A recent systematic review evaluated the effectiveness of strategies to improve healthcare provider (HCP) performance in low-income and middle-income countries. The review identified strategies with varying effects, including in-service training, supervision and group problem-solving. However, whether their effectiveness changed over time remained unclear. In particular, understanding whether effects decay over time is crucial to improve sustainability. METHODS We conducted a secondary analysis of data from the aforementioned review to explore associations between time and effectiveness. We calculated effect sizes (defined as percentage-point (%-point) changes) for HCP practice outcomes (eg, percentage of patients correctly treated) at each follow-up time point after the strategy was implemented. We estimated the association between time and effectiveness using random-intercept linear regression models with time-specific effect sizes clustered within studies and adjusted for baseline performance. RESULTS The primary analysis included 37 studies, and a sensitivity analysis included 77 additional studies. For training, every additional month of follow-up was associated with a 0.19 %-point decrease in effectiveness (95% CI: -0.36 to -0.03). For training combined with supervision, every additional month was associated with a 0.40 %-point decrease in effectiveness (95% CI: -0.68 to -0.12). Time trend results for supervision were inconclusive. For group problem-solving alone, time was positively associated with effectiveness, with a 0.50 %-point increase in effect per month (95% CI: 0.37 to 0.64). Group problem-solving combined with training was associated with large improvements, and its effect was not associated with time. CONCLUSIONS Time trends in the effectiveness of different strategies to improve HCP practices vary among strategies. Programmes relying solely on in-service training might need periodical refresher training or, better still, consider combining training with group problem-solving. Although more high-quality research is needed, these results, which are important for decision-makers as they choose which strategies to use, underscore the utility of studies with multiple post-implementation measurements so sustainability of the impact on HCP practices can be assessed.
Collapse
Affiliation(s)
- Catherine Arsenault
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, Massachusetts, USA
| | | | - Dennis Ross-Degnan
- Harvard Medical School, Boston, Massachusetts, USA
- Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
| | - David H Peters
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Sanam Roder-DeWan
- Department of Health Systems, Impact Evaluation and Policy, Ifakara Health Institute, Dar es Salaam, United Republic of Tanzania
| | - Margaret E Kruk
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, Massachusetts, USA
| | - Alexander K Rowe
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| |
Collapse
|
30
|
Al-Taani GM, Al-Azzam S, Karasneh RA, Sadeq AS, Mazrouei NA, Bond SE, Conway BR, Aldeyab MA. Pharmacists’ Knowledge, Attitudes, Behaviors and Information Sources on Antibiotic Use and Resistance in Jordan. Antibiotics (Basel) 2022; 11:antibiotics11020175. [PMID: 35203777 PMCID: PMC8868190 DOI: 10.3390/antibiotics11020175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 01/21/2022] [Accepted: 01/25/2022] [Indexed: 12/07/2022] Open
Abstract
Antimicrobial resistance (AMR) is a serious healthcare problem that affects public health globally. Appropriate understanding and knowledge of prudent antimicrobial use and resistance, along with providing evidence-based information sources, are needed for informed antibiotic prescribing practices. This study aimed to assess the knowledge, opportunity, motivation, behavior of pharmacists and their information sources regarding antibiotic use and resistance in Jordan. An online cross-sectional questionnaire was developed and administered to pharmacists during the period of July–September 2021. The survey is an adapted version of the validated European Centre for Disease Prevention and Control (ECDC) survey for antibiotic use and resistance. Pharmacists from all sectors (n = 384), of whom 276 (71.9%) were community pharmacists, completed an online questionnaire. While respondents scored highly (>87%) on knowledge on effective use, unnecessary use, and associated side effects of antibiotics, lower scores were recorded for knowledge on the spread of antibiotic resistance (52.9%). Pharmacists support easy access to guidelines on managing infections in 56% of cases, and easy access to materials advising prudent antibiotic use and resistance in 39.8% of cases. One-third of respondents (37.0%) reported no knowledge of any initiatives on antibiotic awareness and resistance. Pharmacists were aware (13.3%), unaware (36.2%), or unsure (50.5%) of the existence of a national antibiotic resistance action plan. Pharmacists indicated an interest in receiving more information on resistance to antibiotics (55.2%), medical conditions for which antibiotics are used (53.1%), how to use antibiotics (45.1%), prescribing of antibiotics (34.4%), and links between the health of humans, animals, and the environment (28.6%). Findings can inform antimicrobial stewardship with required interventions to improve antibiotic use.
Collapse
Affiliation(s)
- Ghaith M. Al-Taani
- Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmacy, Yarmouk University, Irbid 21163, Jordan;
| | - Sayer Al-Azzam
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid 22110, Jordan;
| | - Reema A. Karasneh
- Department of Basic Medical Sciences, Faculty of Medicine, Yarmouk University, Irbid 21163, Jordan;
| | - Adel Shaban Sadeq
- College of Pharmacy, Al Ain University, Al Ain 64141, United Arab Emirates;
| | - Nadia Al Mazrouei
- Department of Pharmacy Practice and Pharmacotherapeutics, College of Pharmacy, University of Sharjah, Sharjah 27272, United Arab Emirates;
| | - Stuart E. Bond
- Pharmacy Department, Mid Yorkshire Hospitals NHS Trust, Wakefield WF1 4DG, UK;
| | - Barbara R. Conway
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield HD1 3DH, UK;
- Institute of Skin Integrity and Infection Prevention, University of Huddersfield, Huddersfield HD1 3DH, UK
| | - Mamoon A. Aldeyab
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield HD1 3DH, UK;
- Correspondence: ; Tel.: +0044-01484-472825
| |
Collapse
|
31
|
Daga A, Nguyen OT, Moothedan E, Czyz DM, Faldu A, Ham T, Goyal A, Motwani K, Feller DB. Antibiotic prescribing patterns for acute respiratory infections in a free clinic network: A pooled cross-sectional study. DRUGS & THERAPY PERSPECTIVES 2022; 38:51-55. [PMID: 35755971 PMCID: PMC9232164 DOI: 10.1007/s40267-021-00883-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
In the United States, overprescribing of antibiotics for viral respiratory infections and antimicrobial resistance continue to be public health concerns. To date, no literature has focused on antibiotic prescribing patterns from free clinics. To address this gap, we used patient-level data from a student-run free clinic network of four primary care clinics to assess factors associated with inappropriate antibiotic prescribing for viral respiratory infections. Treatment plans were deemed inappropriate if any type of antibiotic was prescribed. We used unpaired t-tests and chi-square tests to assess for differences in receiving an inappropriate antibiotic prescription by patient-level factors (i.e., age, race/ethnicity, sex, educational attainment, preferred language, insurance status). Of 298 visits, 22.5% did not meet treatment guidelines. No patient-level factors studied were associated with inappropriate antibiotic prescribing. Our findings suggest other factors, beyond patient-level, may be drivers of variation in antibiotic prescribing in free clinics.
Collapse
Affiliation(s)
- Anshul Daga
- Department of Community Health & Family Medicine, University of Florida, Gainesville, FL
| | - Oliver T. Nguyen
- Department of Community Health & Family Medicine, University of Florida, Gainesville, FL
| | - Elijah Moothedan
- Department of Community Health & Family Medicine, University of Florida, Gainesville, FL
| | - Daniel M. Czyz
- Department of Microbiology and Cell Science, University of Florida, Gainesville, FL
| | - Aashi Faldu
- Department of Community Health & Family Medicine, University of Florida, Gainesville, FL
| | - Taylor Ham
- Department of Community Health & Family Medicine, University of Florida, Gainesville, FL
| | - Arshia Goyal
- Department of Community Health & Family Medicine, University of Florida, Gainesville, FL
| | - Kartik Motwani
- Department of Community Health & Family Medicine, University of Florida, Gainesville, FL
| | - David B. Feller
- Department of Community Health & Family Medicine, University of Florida, Gainesville, FL
| |
Collapse
|
32
|
Liu C, Wang D, Duan L, Zhang X, Liu C. Coping With Diagnostic Uncertainty in Antibiotic Prescribing: A Latent Class Study of Primary Care Physicians in Hubei China. Front Public Health 2021; 9:741345. [PMID: 34957007 PMCID: PMC8695689 DOI: 10.3389/fpubh.2021.741345] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 11/12/2021] [Indexed: 11/25/2022] Open
Abstract
Background: Misuse of antibiotics is prevalent worldwide and primary care is a major contributor. Although a clear diagnosis is fundamental for rational antibiotic use, primary care physicians often struggle with diagnostic uncertainty. However, we know little about how physicians cope with this situation and its association with antibiotic prescribing. Methods: A total of 583 primary care physicians were surveyed using the Dealing with Uncertainty Questionnaire. Their prescriptions (n = 949,181) over the year 2018 were retrieved retrospectively. Two categories of behavioral patterns of participants were identified based on latent class analyses (high vs. low openness and collaborativeness) in responding to diagnostic uncertainty. Multi-level logistic regression models were established to determine the associations between these behavioral patterns and antibiotic prescribing (overall and broad-spectrum antibiotics) for illness without an indication for antibiotics and those with a conditional indication for antibiotics, respectively, after adjustment for variations of patient (level one) and physician (level two) characteristics. Results: Most physicians reported open communications with their patients (80.96%), collected further information (85.08%), and referred patients to specialists (68.95%) in dealing with diagnostic uncertainly. More than half (56.95%) sought help from colleagues. Less than 20% acted on intuition or adopted a “wait and see” strategy. About 40% participants (n = 238) were classified into the group of low openness and collaborativeness in coping with diagnostic uncertainty. They were more likely to prescribe antibiotics for the recorded illness without an indication for antibiotics (AOR = 1.013 for all antibiotics, p = 0.024; AOR = 1.047 for broad-spectrum antibiotics, p < 0.001), as well as for the recorded illness with a conditional indication for antibiotics (AOR = 1.226 for all antibiotic, p < 0.001; AOR = 1.257 for broad-spectrum antibiotics, p < 0.001). Conclusion: Low tolerance with diagnostic uncertainty is evident in primary care. Inappropriate and over antibiotic prescribing is shaped by physicians' coping methods of diagnostic uncertainty. Physicians' openness and collaborativeness in responding to diagnostic uncertainty is associated with lower antibiotic prescribing in primary care. Interventions targeting on better management of diagnostic uncertainty may offer a promising approach in reducing antibiotic use in primary care.
Collapse
Affiliation(s)
- Chaojie Liu
- School of Psychology and Public Health, La Trobe University, Melbourne, VIC, Australia
| | - Dan Wang
- School of Medicine and Health Management, Tongji Medical School, Huazhong University of Science and Technology, Wuhan, China
| | - Lixia Duan
- School of Medicine and Health Management, Tongji Medical School, Huazhong University of Science and Technology, Wuhan, China
| | - Xinping Zhang
- School of Medicine and Health Management, Tongji Medical School, Huazhong University of Science and Technology, Wuhan, China
| | - Chenxi Liu
- School of Medicine and Health Management, Tongji Medical School, Huazhong University of Science and Technology, Wuhan, China
| |
Collapse
|
33
|
Mortrude GC, Rehs MT, Sherman KA, Gundacker ND, Dysart CE. Implementation of Veterans Affairs Primary Care Antimicrobial Stewardship Interventions For Asymptomatic Bacteriuria And Acute Respiratory Infections. Open Forum Infect Dis 2021; 8:ofab449. [PMID: 34909435 PMCID: PMC8665674 DOI: 10.1093/ofid/ofab449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 08/31/2021] [Indexed: 11/14/2022] Open
Abstract
Background Outpatient antimicrobial prescribing is an important target for antimicrobial stewardship (AMS) interventions to decrease antimicrobial resistance. The objective of this study was to design, implement, and evaluate the impact of AMS interventions focused on asymptomatic bacteriuria (ASB) and acute respiratory infections (ARIs) in the primary care setting. Methods This stepped-wedge trial evaluated the impact of multifaceted educational interventions to providers on adult patients presenting to primary care clinics for ARIs and ASB. The primary outcome was percentage of overall antibiotic prescriptions as a composite of prescriptions for ASB, acute bronchitis, upper respiratory infection not otherwise specified, uncomplicated sinusitis, and uncomplicated pharyngitis. Secondary outcomes were the individual components of the primary outcome; a composite safety endpoint of related hospital, emergency department, or primary care visits within 4 weeks; antibiotic selection appropriateness; and patient satisfaction surveys. Results A total of 887 patients were included (405 preintervention and 482 postintervention). After controlling for type I error using Bonferroni correction, the primary outcome was not significantly different between groups (56% vs 49%). There was a statistically significant decrease in prescriptions for acute bronchitis (20.99% vs 12.66%; P = .0003). Appropriateness of antibiotic prescriptions for uncomplicated sinusitis (odds ratio [OR], 4.96 [95% confidence interval {CI}, 1.79–13.75]; P = .0021) and pharyngitis (OR, 5.36 [95% CI, 1.93–14.90]; P = .0013) was improved in the postintervention vs the preintervention group. The composite safety outcome and patient satisfaction surveys did not differ between groups. Conclusions Multifaceted educational interventions targeting providers can improve antibiotic prescribing for indications rarely requiring antimicrobials without increasing re-visits or patient satisfaction surveys.
Collapse
Affiliation(s)
- Grace C Mortrude
- Infectious Diseases Service Pharmacy, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin, USA
| | - Mary T Rehs
- Primary Care, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin, USA
| | - Katherine A Sherman
- Research Division, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin, USA
| | - Nathan D Gundacker
- Infectious Diseases, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin, USA.,Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Claire E Dysart
- Infectious Diseases Service Pharmacy, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin, USA
| |
Collapse
|
34
|
Goebel MC, Trautner BW, Grigoryan L. The Five Ds of Outpatient Antibiotic Stewardship for Urinary Tract Infections. Clin Microbiol Rev 2021; 34:e0000320. [PMID: 34431702 PMCID: PMC8404614 DOI: 10.1128/cmr.00003-20] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Urinary tract infections (UTI) are one of the most common indications for antibiotic prescriptions in the outpatient setting. Given rising rates of antibiotic resistance among uropathogens, antibiotic stewardship is critically needed to improve outpatient antibiotic use, including in outpatient clinics (primary care and specialty clinics) and emergency departments. Outpatient clinics are in general a neglected practice area in antibiotic stewardship programs, yet most antibiotic use in the United States is in the outpatient setting. This article provides a comprehensive review of antibiotic stewardship strategies for outpatient UTI in the adult population, with a focus on the "five Ds" of stewardship for UTI, including right diagnosis, right drug, right dose, right duration, and de-escalation. Stewardship interventions that have shown success for improving prescribing for outpatient UTI are discussed, including diagnostic stewardship strategies, such as reflex urine cultures, computerized decision support systems, and modified reporting of urine culture results. Among the many challenges to achieving stewardship for UTI in the outpatient setting, some of the most important are diagnostic uncertainty, increasing antibiotic resistance, limitations of guidelines, and time constraints of stewardship personnel and front-line providers. This article presents a stewardship framework, built on current evidence and expert opinion, that clinicians can use to guide their own outpatient management of UTI.
Collapse
Affiliation(s)
- Melanie C. Goebel
- Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Barbara W. Trautner
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Larissa Grigoryan
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, Texas, USA
| |
Collapse
|
35
|
Boeijen JA, van der Velden AW, Hullegie S, Platteel TN, Zwart DLM, Damoiseaux RAMJ, Venekamp RP, van de Pol AC. Common Infections and Antibiotic Prescribing during the First Year of the COVID-19 Pandemic: A Primary Care-Based Observational Cohort Study. Antibiotics (Basel) 2021; 10:antibiotics10121521. [PMID: 34943733 PMCID: PMC8698485 DOI: 10.3390/antibiotics10121521] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 12/09/2021] [Accepted: 12/09/2021] [Indexed: 12/27/2022] Open
Abstract
Presentation and antibiotic prescribing for common infectious disease episodes decreased substantially during the first COVID-19 pandemic wave in Dutch general practice. We set out to determine the course of these variables during the first pandemic year. We conducted a retrospective observational cohort study using routine health care data from the Julius General Practitioners’ Network. All patients registered in the pre-pandemic year (n = 425,129) and/or during the first pandemic year (n = 432,122) were included. Relative risks for the number of infectious disease episodes (respiratory tract/ear, urinary tract, gastrointestinal, and skin), in total and those treated with antibiotics, and proportions of episodes treated with antibiotics (prescription rates) were calculated. Compared to the pre-pandemic year, primary care presentation for common infections remained lower during the full first pandemic year (RR, 0.77; CI, 0.76–0.78), mainly attributed to a sustained decline in respiratory tract/ear and gastrointestinal infection episodes. Presentation for urinary tract and skin infection episodes declined during the first wave, but returned to pre-pandemic levels during the second and start of the third wave. Antibiotic prescription rates were lower during the full first pandemic year (24%) as compared to the pre-pandemic year (28%), mainly attributed to a 10% lower prescription rate for respiratory tract/ear infections; the latter was not accompanied by an increase in complications. The decline in primary care presentation for common infections during the full first COVID-19 pandemic year, together with lower prescription rates for respiratory tract/ear infections, resulted in a substantial reduction in antibiotic prescribing in Dutch primary care.
Collapse
|
36
|
Gágyor I, Greser A, Heuschmann P, Rücker V, Maun A, Bleidorn J, Heintze C, Jede F, Eckmanns T, Klingeberg A, Mentzel A, Schmiemann G. REDuction of Antibiotic RESistance (REDARES) in urinary tract infections using treatments according to national clinical guidelines: study protocol for a pragmatic randomized controlled trial with a multimodal intervention in primary care. BMC Infect Dis 2021; 21:990. [PMID: 34556027 PMCID: PMC8461906 DOI: 10.1186/s12879-021-06660-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 09/06/2021] [Indexed: 11/14/2022] Open
Abstract
Background Urinary tract infections (UTIs) are a common cause of prescribing antibiotics in family medicine. In Germany, about 40% of UTI-related prescriptions are second-line antibiotics, which contributes to emerging resistance rates. To achieve a change in the prescribing behaviour among family physicians (FPs), this trial aims to implement the guideline recommendations in German family medicine. Methods/design In a randomized controlled trial, a multimodal intervention will be developed and tested in family practices in four regions across Germany. The intervention will consist of three elements: information on guideline recommendations, information on regional resistance and feedback of prescribing behaviour for FPs on a quarterly basis. The effect of the intervention will be compared to usual practice. The primary endpoint is the absolute difference in the mean of prescribing rates of second-line antibiotics among the intervention and the control group after 12 months. To detect a 10% absolute difference in the prescribing rate after one year, with a significance level of 5% and a power of 86%, a sample size of 57 practices per group will be needed. Assuming a dropout rate of 10%, an overall number of 128 practices will be required. The accompanying process evaluation will provide information on feasibility and acceptance of the intervention. Discussion If proven effective and feasible, the components of the intervention can improve adherence to antibiotic prescribing guidelines and contribute to antimicrobial stewardship in ambulatory care. Trial registration DRKS, DRKS00020389, Registered 30 January 2020, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00020389.
Collapse
Affiliation(s)
- Ildikó Gágyor
- Department of General Practice, University Hospital Wuerzburg, Josef-Schneider-Str. 2, D7, 97080, Wuerzburg, Germany
| | - Alexandra Greser
- Department of General Practice, University Hospital Wuerzburg, Josef-Schneider-Str. 2, D7, 97080, Wuerzburg, Germany.
| | - Peter Heuschmann
- Institute for Clinical Epidemiology and Biometry (IKE-B), University of Wuerzburg, Wuerzburg, Germany.,Clinical Trial Centre Wuerzburg, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Viktoria Rücker
- Institute for Clinical Epidemiology and Biometry (IKE-B), University of Wuerzburg, Wuerzburg, Germany
| | - Andy Maun
- Division of General Practice, Faculty of Medicine, Medical Center, University of Freiburg, Freiburg, Germany
| | - Jutta Bleidorn
- Department of General Practice, University Hospital Jena, Jena, Thuringia, Germany
| | - Christoph Heintze
- Department of General Practice, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Felix Jede
- Department of General Practice, University Hospital Wuerzburg, Josef-Schneider-Str. 2, D7, 97080, Wuerzburg, Germany
| | | | | | - Anja Mentzel
- Division of General Practice, Faculty of Medicine, Medical Center, University of Freiburg, Freiburg, Germany
| | - Guido Schmiemann
- Department of Health Services Research, Institute for Public Health and Nursing Research, University of Bremen, Bremen, Germany
| |
Collapse
|
37
|
Beahm NP, Smyth DJ, Tsuyuki RT. Antimicrobial utilization and stewardship in patients with uncomplicated urinary tract infections managed by pharmacists in the community: A sub-study of the R xOUTMAP trial. JOURNAL OF THE ASSOCIATION OF MEDICAL MICROBIOLOGY AND INFECTIOUS DISEASE CANADA = JOURNAL OFFICIEL DE L'ASSOCIATION POUR LA MICROBIOLOGIE MEDICALE ET L'INFECTIOLOGIE CANADA 2021; 6:205-212. [PMID: 36337761 PMCID: PMC9615465 DOI: 10.3138/jammi-2020-0047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 06/04/2021] [Indexed: 06/16/2023]
Abstract
BACKGROUND Urinary tract infections (UTIs) often lead to suboptimal antibacterial use. Pharmacists are accessible primary care professionals who have an important role to play in antimicrobial stewardship. Our objective was to evaluate the appropriateness of pharmacists' antibacterial prescribing for patients with uncomplicated UTI. METHODS We conducted a prospective registry trial with 39 community pharmacies in New Brunswick, Canada. Adult patients were enrolled if they presented to the pharmacy with either symptoms of UTI with no current antibacterial treatment (pharmacist-initial arm) or an antibacterial prescription for UTI from a physician (physician-initial arm). Pharmacists assessed patients; patients with complicating factors or red flags for systemic illness or pyelonephritis were excluded. Pharmacists prescribed antibacterial therapy or modified antibacterial therapy, provided education only, or referred to a physician, as appropriate. Antibacterial therapy prescribed was compared between study arms. RESULTS Seven hundred fifty patients were enrolled (87% pharmacist-initial arm). The most commonly prescribed agents in the pharmacist-initial arm were nitrofurantoin (88.4%), sulfamethoxazole-trimethoprim (TMP-SMX) (7.8%), and fosfomycin (2.1%); in the physician-initial arm, nitrofurantoin (55.3%), TMP-SMX (25.5%), and fluoroquinolones (10.6%) were prescribed. Therapy was guideline concordant for 95.1% of patients in the pharmacist-initial arm and 35.1% of patients in the physician-initial arm (p < 0.001). For guideline-discordant therapy from physicians, pharmacists prescribed to optimize therapy for 45.9% of patients. CONCLUSION Treatment was highly guideline concordant when pharmacist initiated, with physicians prescribing longer treatment durations and more fluoroquinolones. This represents an important opportunity for antimicrobial stewardship interventions by pharmacists in the community.
Collapse
Affiliation(s)
- Nathan P Beahm
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Daniel J Smyth
- Division of Infectious Diseases, Department of Internal Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
- Horizon Health Network, Moncton, New Brunswick, Canada
| | - Ross T Tsuyuki
- Departments of Pharmacology and Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| |
Collapse
|
38
|
Yau JW, Thor SM, Tsai D, Speare T, Rissel C. Antimicrobial stewardship in rural and remote primary health care: a narrative review. Antimicrob Resist Infect Control 2021; 10:105. [PMID: 34256853 PMCID: PMC8278763 DOI: 10.1186/s13756-021-00964-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 05/28/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Antimicrobial resistance is an emerging problem worldwide and poses a significant threat to human health. Antimicrobial stewardship programmes are being implemented in health systems globally, primarily in hospitals, to address the growing threat of antimicrobial resistance. Despite the significance of primary health care services in providing health care to communities, antimicrobial stewardship programmes are not well established in this sector, especially in rural and remote settings. This narrative review aims to identify in rural and remote primary health care settings the (1) correlation of antimicrobial resistance with antibiotic prescribing and volume of antibiotic use, (2) appropriateness of antimicrobial prescribing, (3) risk factors associated with inappropriate use/prescribing of antibiotics, and (4) effective antimicrobial stewardship strategies. METHODS The international literature was searched for English only articles between 2000 and 2020 using specified keywords. Seven electronic databases were searched: Scopus, Cochrane, Embase, CINAHL, PubMed, Ovid Medline and Ovid Emcare. Publication screening and analysis were conducted using Joanna Briggs Institute systematic review tools. RESULTS Fifty-one eligible articles were identified. Inappropriate and excessive antimicrobial prescribing and use directly led to increases in antimicrobial resistance. Increasing rurality of practice is associated with disproportionally higher rates of inappropriate prescribing compared to those in metropolitan areas. Physician knowledge, attitude and behaviour play important roles in mediating antimicrobial prescribing, with strong intrinsic and extrinsic influences including patient factors. Antimicrobial stewardship strategies in rural and remote primary health care settings focus on health care provider and patient education, clinician support systems, utility of antimicrobial resistance surveillance, and policy changes. Results of these interventions were generally positive with decreased antimicrobial resistance rates and improved appropriateness of antimicrobial prescribing. CONCLUSIONS Inappropriate prescribing and excessive use of antimicrobials are an important contributor to the increasing resistance towards antimicrobial agents particularly in rural and remote primary health care. Antimicrobial stewardship programmes in the form of education, clinical support, surveillance, and policies have been mostly successful in reducing prescribing rates and inappropriate prescriptions. The narrative review highlighted the need for longer interventions to assess changes in antimicrobial resistance rates. The review also identified a lack of differentiation between rural and remote contexts and Indigenous health was inadequately addressed. Future research should have a greater focus on effective interventional components and patient perspectives.
Collapse
Affiliation(s)
- Jun Wern Yau
- Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, 47500, Bandar Sunway, Malaysia
| | - Sze Mun Thor
- Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, 47500, Bandar Sunway, Malaysia
| | - Danny Tsai
- Flinders University- Rural and Remote Health NT, Royal Darwin Hospital Campus, Rocklands Drive, Tiwi, NT, 0810, Australia.,Alice Springs Hospital, Central Australian Health Service, Alice Springs, NT, 0870, Australia.,University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia
| | - Tobias Speare
- Flinders University- Rural and Remote Health NT, Royal Darwin Hospital Campus, Rocklands Drive, Tiwi, NT, 0810, Australia.,Alice Springs Hospital, Central Australian Health Service, Alice Springs, NT, 0870, Australia
| | - Chris Rissel
- Flinders University- Rural and Remote Health NT, Royal Darwin Hospital Campus, Rocklands Drive, Tiwi, NT, 0810, Australia.
| |
Collapse
|
39
|
Changes in antibiotic prescription following an education strategy for acute respiratory infections. NPJ Prim Care Respir Med 2021; 31:34. [PMID: 34083534 PMCID: PMC8175562 DOI: 10.1038/s41533-021-00247-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 02/26/2021] [Indexed: 11/29/2022] Open
Abstract
The objective of this study was to assess the impact of an education intervention for primary health care physicians, based on the knowledge of clinical practice guidelines and availability of rapid antigen detection test for group A streptococci (GAS), on the improvement of antibiotic prescription for patients with acute respiratory tract infections. Before and after the intervention, physicians collected data from ten consecutive patients who attended during a 3-week period. This process was performed twice a year for 6 consecutive years (2012–2017). A total of 18,001 patients were visited by 391 primary care physicians during the study period, 55.6% before intervention and 44.4% after intervention. After intervention, the antibiotic prescription decreased significantly, from 33.0 to 23.4% (p < 0.01). However, there was a statistically significant increase (p < 0.01) in the use of penicillins. This study, carried out in daily practice conditions, confirms that the educational strategy was associated with an overall reduction in the use of antibiotics and an improvement in the antibiotic prescription profile in acute respiratory tract infections.
Collapse
|
40
|
Ashiru-Oredope D, Hopkins S, Vasandani S, Umoh E, Oloyede O, Nilsson A, Kinsman J, Elsert L, Monnet DL. Healthcare workers' knowledge, attitudes and behaviours with respect to antibiotics, antibiotic use and antibiotic resistance across 30 EU/EEA countries in 2019. ACTA ACUST UNITED AC 2021; 26. [PMID: 33769250 PMCID: PMC7995558 DOI: 10.2807/1560-7917.es.2021.26.12.1900633] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background While several studies have assessed knowledge, attitudes and behaviours of the public, physicians and medical students in a number of EU/EEA countries with respect to antibiotic use and antibiotic resistance, there is a paucity of literature for other healthcare workers. This survey aimed to fill this gap. Methods A 43-item online questionnaire was developed, validated and pilot-tested through a modified Delphi consensus process involving 87 Project Advisory Group (PAG) members, including national representatives and members of European health professional groups. The survey was distributed by the PAG and via social media to healthcare workers in 30 EU/EEA countries. Results Respondents (n = 18,365) from 30 EU/EEA countries participated. Knowledge of antibiotics and antibiotic use was higher (97%) than knowledge of development and spread of antibiotic resistance (75%). Sixty percent of respondents stated they had received information on avoiding unnecessary prescribing, administering or dispensing of antibiotics. Among respondents who prescribed, administered or dispensed antibiotics, 55% had provided advice on prudent antibiotic use or management of infections to patients, but only 17% had given resources (leaflets or pamphlets). For community and hospital prescribers, fear of patient deterioration or complications was the most frequent reason (43%) for prescribing antibiotics that were considered unnecessary. Community prescribers were almost twice as likely as hospital prescribers to prescribe antibiotics due to time constraints or to maintain patient relationships. Conclusion It is important to move from raising awareness about prudent antibiotic use and antibiotic resistance among healthcare workers to designing antimicrobial stewardship interventions aimed at changing relevant behaviours.
Collapse
Affiliation(s)
| | | | | | - Eno Umoh
- Public Health England (PHE), London, United Kingdom
| | | | - Andrea Nilsson
- European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden
| | - John Kinsman
- European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden
| | - Linda Elsert
- European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden
| | - Dominique L Monnet
- European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden
| | -
- The members of the #ECDCAntibioticSurvey Project Advisory Group are listed at the end of the article
| |
Collapse
|
41
|
Sánchez X, Orrico M, Morillo T, Manzano A, Jimbo R, Armijos L. Reducing unnecessary antibiotic prescription through implementation of a clinical guideline on self-limiting respiratory tract infections. PLoS One 2021; 16:e0249475. [PMID: 33793627 PMCID: PMC8016285 DOI: 10.1371/journal.pone.0249475] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 03/18/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Clinical guidelines (CG) are used to reduce variability in practice when the scientific evidence is sparse or when multiple therapies are available. The development and implementation of evidence-based CG is intended to organize and provide the best available evidence to support clinical decision making in order to improve quality of care. Upper respiratory tract infections (URTI) are the leading cause of misuse of antibiotics and a CG may reduce the unnecessary antibiotic prescription. METHODS The aim of this quasi-experimental, before-after study was to analyze the short- and long-term effects of the implementation of a CG to decrease the rate of antibiotic prescription in URTI cases in the emergency department of a third level private hospital in Quito, Ecuador. The study included 444 patients with a main diagnosis of URTI. They were distributed in three groups: a baseline cohort 2011 (n = 114), a first post-implementation cohort 2011 (n = 114), and a later post-implementation cohort 2018 (n = 216). The implementation strategy consisted of five key steps: acceptance of the need for implementation of the CG, dissemination of the CG, an educational campaign, constant feedback, and sustainability of the strategy through continuous training. RESULTS The results of this study show a 42.90% of antibiotic prescription rate before the CG implementation. After the implementation of the CG, the prescription rate of antibiotics was significantly reduced by 24.5% (42.9% vs 18.4%, p<0.0001) and the appropriate antibiotic prescription rate was significantly increased by 44.2% (22.4% vs 66.6%, p<0.0001) in the first post-implementation cohort 2011. There was not a significant difference in antibiotic prescription rate and appropriate antibiotic prescription rate between two post-implementation cohorts: 18.4% vs 25.9% (p = 0.125) and 66.6% vs 50% (p = 0.191), respectively. CONCLUSIONS The implementation of CGs decreases the rate of antibiotic prescription in URTI cases. The results are remarkable after early implementation, but the effect persists over time. The emphasis must shift from guideline development to strategy implementation.
Collapse
Affiliation(s)
- Xavier Sánchez
- Centro de Investigación para la Salud en América Latina (CISeAL), Pontificia Universidad Católica del Ecuador, Quito, Ecuador
- Facultad de Medicina, Postgrado de Medicina Familiar y Comunitaria, Pontificia Universidad Católica del Ecuador, Quito, Ecuador
- Universidad Alcalá de Henares, Madrid, España
| | - María Orrico
- Facultad de Medicina, Postgrado de Medicina Familiar y Comunitaria, Pontificia Universidad Católica del Ecuador, Quito, Ecuador
| | - Toa Morillo
- Facultad de Medicina, Postgrado de Medicina Familiar y Comunitaria, Pontificia Universidad Católica del Ecuador, Quito, Ecuador
| | - Andrea Manzano
- Facultad de Medicina, Postgrado de Medicina Familiar y Comunitaria, Pontificia Universidad Católica del Ecuador, Quito, Ecuador
| | - Ruth Jimbo
- Centro de Investigación para la Salud en América Latina (CISeAL), Pontificia Universidad Católica del Ecuador, Quito, Ecuador
- Facultad de Medicina, Postgrado de Medicina Familiar y Comunitaria, Pontificia Universidad Católica del Ecuador, Quito, Ecuador
- Universidad Alcalá de Henares, Madrid, España
| | - Luciana Armijos
- Centro de Investigación para la Salud en América Latina (CISeAL), Pontificia Universidad Católica del Ecuador, Quito, Ecuador
- Facultad de Medicina, Postgrado de Medicina Familiar y Comunitaria, Pontificia Universidad Católica del Ecuador, Quito, Ecuador
| |
Collapse
|
42
|
Machowska A, Marrone G, Saliba-Gustafsson P, Borg MA, Saliba-Gustafsson EA, Stålsby Lundborg C. Impact of a Social Marketing Intervention on General Practitioners' Antibiotic Prescribing Practices for Acute Respiratory Tract Complaints in Malta. Antibiotics (Basel) 2021; 10:371. [PMID: 33807404 PMCID: PMC8066227 DOI: 10.3390/antibiotics10040371] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 03/25/2021] [Accepted: 03/26/2021] [Indexed: 11/16/2022] Open
Abstract
Introduction: Antibiotics are commonly prescribed in primary care for acute respiratory tract complaints (aRTCs), often inappropriately. Social marketing interventions could improve prescribing in such settings. We evaluate the impact of a social marketing intervention on general practitioners' (GPs') antibiotic prescribing for aRTCs in Malta. Methods: Changes in GPs' antibiotic prescribing were monitored over two surveillance periods between 2015 and 2018. Primary outcome: change in antibiotic prescription for aRTCs. Secondary outcomes: change in antibiotic prescription: (i) for immediate use, (ii) for delayed antibiotic prescription, (iii) by diagnosis, and (iv) by antibiotic class. Data were analysed using clustered analysis and interrupted time series analysis (ITSA). Results: Of 33 participating GPs, 18 successfully completed the study. Although clustered analyses showed a significant 3% decrease in overall antibiotic prescription (p = 0.024), ITSA showed no significant change overall (p = 0.264). Antibiotic prescription decreased significantly for the common cold (p < 0.001), otitis media (p = 0.044), and sinusitis (p = 0.004), but increased for pharyngitis (p = 0.015). Conclusions: The intervention resulted in modest improvements in GPs' antibiotic prescribing. A more top-down approach will likely be required for future initiatives to be successful in this setting, focusing on diagnostic and prescribing support like rapid diagnostic testing, prescribing guidelines, and standardised delayed antibiotic prescriptions.
Collapse
Affiliation(s)
- Anna Machowska
- Department of Global Public Health, Health Systems and Policy: Improving Use of Medicines, Karolinska Institutet, 171 77 Stockholm, Sweden; (A.M.); (G.M.); (C.S.L.)
| | - Gaetano Marrone
- Department of Global Public Health, Health Systems and Policy: Improving Use of Medicines, Karolinska Institutet, 171 77 Stockholm, Sweden; (A.M.); (G.M.); (C.S.L.)
| | - Peter Saliba-Gustafsson
- Center for Molecular Medicine at BioClinicum, Cardiovascular Medicine Unit, Department of Medicine, Karolinska Institutet, Karolinska University Hospital Solna, 171 76 Stockholm, Sweden;
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, CA 94305, USA
| | - Michael A. Borg
- Department of Infection Prevention and Control, Mater Dei Hospital, MSD 2090 Msida, Malta;
- Faculty of Medicine and Surgery, University of Malta, MSD 2090 Msida, Malta
| | - Erika A. Saliba-Gustafsson
- Department of Global Public Health, Health Systems and Policy: Improving Use of Medicines, Karolinska Institutet, 171 77 Stockholm, Sweden; (A.M.); (G.M.); (C.S.L.)
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Cecilia Stålsby Lundborg
- Department of Global Public Health, Health Systems and Policy: Improving Use of Medicines, Karolinska Institutet, 171 77 Stockholm, Sweden; (A.M.); (G.M.); (C.S.L.)
| |
Collapse
|
43
|
Chater A, Milton S, Green J, Gilworth G, Roposch A. Understanding physician behaviour in the 6-8 weeks hip check in primary care: a qualitative study using the COM-B. BMJ Open 2021; 11:e044114. [PMID: 33741671 PMCID: PMC7986785 DOI: 10.1136/bmjopen-2020-044114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVES A compulsory hip check is performed on an infant at 6-8 weeks in primary care for the detection of developmental dysplasia of the hip (DDH). Missed diagnoses and infants incorrectly labelled with DDH remain an important problem. The nature of physician behaviour as a likely source of this problem has not been explored. The aims of this study were to make a behavioural diagnosis of general practitioners (GPs) who perform these hip checks, and identify potential behavioural change techniques that could make the hip checks more effective. DESIGN Qualitative study with in-depth semistructured interviews of 6-8 weeks checks. We used the Capability, Opportunity, Motivation and Behaviour model in making a behavioural diagnosis and elicited factors that can be linked to improving the assessment. SETTING Primary care. PARTICIPANTS 17 GPs (15 female) who had between 5 and 34 years of work experience were interviewed. RESULTS Capability related to knowledge of evidence-based criteria and skill to identify DDH were important behavioural factors. Both physical (clinic time and space) and social (practice norms), opportunity were essential for optimal behaviour. Furthermore, motivation related to the importance of the 6-8 weeks check and confidence to perform the check and refer appropriately were identified in the behavioural diagnosis. CONCLUSION Aspects of capability, opportunity and motivation affect GPs' diagnosis and referral behaviours in relation to DDH. The findings from this work extend current knowledge and will inform the development of an intervention aimed at improving the diagnosis of DDH.
Collapse
Affiliation(s)
- Angel Chater
- Department of Sport Science and Physical, University of Bedfordshire, Luton, UK
| | - Sarah Milton
- Department of Population Health Sciences, King's College London, London, UK
| | - Judith Green
- Department of Population Health Sciences, King's College London, London, UK
| | - Gill Gilworth
- Department of Population Health Sciences, King's College London, London, UK
| | - Andreas Roposch
- Institute of Child Health, University College London, London, UK
- Department of Orthopaedic Surgery, Great Ormond Street Hospital for Children, London, UK
| |
Collapse
|
44
|
Nair MM, Mahajan R, Burza S, Zeegers MP. Behavioural interventions to address rational use of antibiotics in outpatient settings of low-income and lower-middle-income countries. Trop Med Int Health 2021; 26:504-517. [PMID: 33452857 PMCID: PMC8248115 DOI: 10.1111/tmi.13550] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Objectives To explore the current evidence on interventions to influence antibiotic prescribing behaviour of health professionals in outpatient settings in low‐income and lower‐middle‐income countries, an underrepresented area in the literature. Methods The systematic review protocol for this study was registered in PROSPERO (CRD42020170504). We searched PubMed, Embase and the Cochrane Central Register of Controlled Trials (CENTRAL) for studies relating to antibiotic prescribing of health professionals in outpatient settings in low‐income and lower‐middle‐income countries. Behavioural interventions were classified as persuasive, enabling, restrictive, structural or bundle (mix of different interventions). In total, 3,514 abstracts were screened and 42 studies were selected for full‐text review, with 13 studies included in the final narrative synthesis. Results Of the 13 included studies, five were conducted in Vietnam, two in Sudan, two in Tanzania, two in India and two in Kenya. All studies were conducted in the outpatient or ambulatory setting: eight took place in primary health centres, two in private clinics and three in pharmacies. Our review found that enabling or educational interventions alone may not be sufficient to overcome the ingrained incentives to link revenue generation to sales of antibiotics, and hence, their inappropriate prescription or misuse. Bundle interventions appear to be very effective at changing prescription behaviour among healthcare providers, including drug sellers and pharmacists. Conclusions Multi‐faceted bundle interventions that combine regulation enforcement with face‐to‐face education and peer influence may be more effective than educational interventions alone at curbing inappropriate antibiotic use.
Collapse
Affiliation(s)
- Mohit M Nair
- Nutrition and Translational Research in Metabolism, Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | | | | | - Maurice P Zeegers
- Nutrition and Translational Research in Metabolism, Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| |
Collapse
|
45
|
Taylor M, Liechti S, Palazzi D. Intermittent Education and Audit and Feedback Reduce Inappropriate Prescribing of Oral Third-Generation Cephalosporins for Pediatric Upper Respiratory Tract Infections. Jt Comm J Qual Patient Saf 2021; 47:250-257. [PMID: 33446441 DOI: 10.1016/j.jcjq.2020.12.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 12/07/2020] [Accepted: 12/08/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE In June 2017, leaders within a pediatric ambulatory care network in Houston approached the antimicrobial stewardship team at Texas Children's Hospital with concerns for high oral third-generation cephalosporin (oTGC) use in their clinics. An outpatient quality improvement (QI) team was formed. The specific aim was to reduce inappropriate oTGC prescribing at one clinic ("Clinic A") by 15% in one year. METHODS Following a benchmark analysis of oTGC use at Clinic A, Plan-Do-Study-Act (PDSA) cycles were designed and conducted over one year: one educational session, three individual audit and feedback sessions, and one group feedback session. The primary outcome was the percentage of oTGCs not aligning with American Academy of Pediatrics (AAP) guidelines for bacterial upper respiratory tract infections. Monthly oTGC prescribing at Clinic A was also compared to four control clinics. RESULTS In June 2017, 72% (231/322) of oTGCs prescriptions at Clinic A did not align with AAP guidelines. The most common diagnosis was primary/nonrecurrent acute otitis media. Following interventions, the mean percentage inappropriate oTGCs decreased from 72% to 45% (absolute reduction 27%, p < 0.001), which was sustained the year following the last PDSA cycle (absolute reduction 26%, p < 0.001). Total monthly oTGC prescribing at Clinic A decreased over time, but not in four control clinics. Provider active participation in stewardship activities decreased over time. CONCLUSION Intermittent education and audit and feedback were associated with reduced oTGC misuse at Clinic A but not at four control clinics. Improvements were maintained despite decreased participation in stewardship activities, suggesting that perceptions of ongoing antibiotic audits can help sustain prescribing improvements.
Collapse
|
46
|
Soucy JPR, Low M, Acharya KR, Ellen M, Hulth A, Löfmark S, Garber GE, Watson W, Moran-Gilad J, Fisman DN, MacFadden DR. Evaluation of an automated feedback intervention to improve antimicrobial prescribing among primary care physicians (OPEN Stewardship): protocol for an interrupted time-series and usability analysis in Ontario, Canada and Southern Israel. BMJ Open 2021; 11:e039810. [PMID: 33441352 PMCID: PMC7812099 DOI: 10.1136/bmjopen-2020-039810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Antimicrobial resistance undermines our ability to treat bacterial infections, leading to longer hospital stays, increased morbidity and mortality, and a mounting burden to the healthcare system. Antimicrobial stewardship is increasingly important to safeguard the efficacy of existing drugs, as few new drugs are in the developmental pipeline. While significant progress has been made with respect to stewardship in hospitals, relatively little progress has been made in the primary care setting, where the majority of antimicrobials are prescribed. OPEN Stewardship is an international collaboration to develop an automated feedback platform to improve responsible antimicrobial prescribing among primary care physicians and capable of being deployed across heterogeneous healthcare settings. We describe the protocol for an evaluation of this automated feedback intervention with two main objectives: assessing changes in antimicrobial prescribing among participating physicians and determining the usability and usefulness of the reports. METHODS AND ANALYSIS A non-randomised evaluation of the automated feedback intervention (OPEN Stewardship) will be conducted among approximately 150 primary care physicians recruited from Ontario, Canada and Southern Israel, based on a series of targeted stewardship messages sent using the platform. Using a controlled interrupted time-series analysis and multilevel negative binomial modelling, we will compare the antimicrobial prescribing rates of participants before and after the intervention, and also to the prescribing rates of non-participants (from the same healthcare network) during the same period. We will examine outcomes targeted by the stewardship messages, including prescribing for antimicrobials with duration longer than 7 days and prescribing for indications where antimicrobials are typically unnecessary. Participants will also complete a series of surveys to determine the usability and usefulness of the stewardship reports. ETHICS AND DISSEMINATION All sites have obtained ethics committee approval to recruit providers and access anonymised prescribing data. Dissemination will occur through open-access publication, stakeholder networks and national/international meetings.
Collapse
Affiliation(s)
- Jean-Paul R Soucy
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Marcelo Low
- Chief Physician's Office, Clalit Health Services, Tel Aviv, Israel
| | - Kamal Raj Acharya
- Department of Population Medicine, University of Guelph Ontario Veterinary College, Guelph, Ontario, Canada
| | - Moriah Ellen
- Department of Health Services Management, Guilford Glazer Faculty of Business and Management, University of the Negev, Beer Sheva, Israel
| | - Anette Hulth
- The Public Health Agency of Sweden, Stockholm, Sweden
| | - Sonja Löfmark
- The Public Health Agency of Sweden, Stockholm, Sweden
| | - Gary E Garber
- Infection Prevention and Control, Public Health Ontario, Toronto, Ontario, Canada
- Infectious Diseases, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - William Watson
- Department of Family & Community Medicine, University of Toronto, Toronto, Ontario, Canada
- St Michael's Hospital, Toronto, Ontario, Canada
| | - Jacob Moran-Gilad
- School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - David N Fisman
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Derek R MacFadden
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| |
Collapse
|
47
|
Medina-Perucha L, García-Sangenís A, Moragas A, Gálvez-Hernández P, Cots JM, Lanau-Roig A, Borràs A, Amo I, Monfà R, Llor C, Berenguera A. Autonomy, power dynamics and antibiotic use in primary healthcare: A qualitative study. PLoS One 2020; 15:e0244432. [PMID: 33338078 PMCID: PMC7748265 DOI: 10.1371/journal.pone.0244432] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 12/09/2020] [Indexed: 12/30/2022] Open
Abstract
Antibiotic resistance is a global health concern. Although numerous strategies have tried to reduce inadequate antibiotic prescribing, antibiotics are still prescribed in 60% of acute lower respiratory tract infections (ALRTIs) cases in Catalonia (Spain). This study aims to explore service users' experiences of ALRTIs, the quality and access to healthcare services, and health education. Selective purposive sampling was carried out, based on a prior definition of participant characteristics. These were sex, age, ethnicity, date of the last ALRTI, number of ALRTIs in the last year, and treatments received. Participants with a previous diagnosis of ALRTIs were recruited from three primary health care centres in Barcelona and one in Tarragona. Twenty-nine interviews were conducted between April and June 2019. A content thematic analysis was performed. Three themes were identified: 1) risk perceptions and help-seeking; 2) treatment preferences and antibiotic use; and 3) relationship dynamics and communication with healthcare professionals. Accounts of service users' sense of autonomy towards their health and power dynamics within the healthcare system were apparent. Supporting service users to become reliable, subjective and agentic experts of their health and bodies could help them to voice their healthcare agendas. Power structures embedded within healthcare, political and economic institutions should be challenged so that healthcare services can be co-developed (with service users) and based on service users' autonomy and horizontal relationships. Special consideration should be paid to the intersection of social vulnerabilities. A concordance approach to prescribing could be key to improve the responsible use of antibiotics and to contribute to the prevention of AMR in primary healthcare. The marketisation of health, and the increased demands of private healthcare in Spain due to the financial pressures on public healthcare as a consequence of the financial crisis of 2008 and the COVID-19 pandemic, are a risk for promoting adequate antibiotic prescribing and use. Trial registration The ISAAC-CAT study has been registered in the NCT registry, ID: NCT03931577.
Collapse
Affiliation(s)
- Laura Medina-Perucha
- Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
| | - Ana García-Sangenís
- Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
- Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain
| | - Ana Moragas
- Universitat Rovira i Virgili, Jaume I Health Centre, Institut Català de la Salut, Tarragona, Spain
| | - Pablo Gálvez-Hernández
- Institut Universitari de Pacients (Patients’ University Institut), Universitat Internacional de Catalunya, Barcelona, Spain
- University of Toronto, IHPME-BFON Collaborative PhD Specialization Program in Health Services and Policy Research, Toronto, Ontario, Canada
| | - Josep María Cots
- La Marina Health Centre, Institut Català de la Salut, Associació d’Infermeria Familiar i Comunitària de Catalunya, Barcelona, Spain
| | - Anna Lanau-Roig
- La Marina Health Centre, Institut Català de la Salut, Associació d’Infermeria Familiar i Comunitària de Catalunya, Barcelona, Spain
| | - Alícia Borràs
- Institut Universitari de Pacients (Patients’ University Institut), Universitat Internacional de Catalunya, Barcelona, Spain
- Escola Universitària d'Infermeria, Escoles Universitàries Gimbernat, Universitat Autònoma de Barcelona, Sant Cugat del Vallès, Spain
| | - Isabel Amo
- Institut Universitari de Pacients (Patients’ University Institut), Universitat Internacional de Catalunya, Barcelona, Spain
| | - Ramon Monfà
- Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
- Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain
| | - Carl Llor
- Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
- Via Roma Health Centre, Institut Català de la Salut, Barcelona, Spain
| | - Anna Berenguera
- Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
- Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain
- Departament d'Infermeria, Universitat de Girona, Girona, Spain
| |
Collapse
|
48
|
Borek AJ, Wanat M, Atkins L, Sallis A, Ashiru-Oredope D, Beech E, Butler CC, Chadborn T, Hopkins S, Jones L, McNulty CAM, Roberts N, Shaw K, Taborn E, Tonkin-Crine S. Optimising antimicrobial stewardship interventions in English primary care: a behavioural analysis of qualitative and intervention studies. BMJ Open 2020; 10:e039284. [PMID: 33334829 PMCID: PMC7747536 DOI: 10.1136/bmjopen-2020-039284] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 10/29/2020] [Accepted: 11/20/2020] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE While various interventions have helped reduce antibiotic prescribing, further gains can be made. This study aimed to identify ways to optimise antimicrobial stewardship (AMS) interventions by assessing the extent to which important influences on antibiotic prescribing are addressed (or not) by behavioural content of AMS interventions. SETTINGS English primary care. INTERVENTIONS AMS interventions targeting healthcare professionals' antibiotic prescribing for respiratory tract infections. METHODS We conducted two rapid reviews. The first included qualitative studies with healthcare professionals on self-reported influences on antibiotic prescribing. The influences were inductively coded and categorised using the Theoretical Domains Framework (TDF). Prespecified criteria were used to identify key TDF domains. The second review included studies of AMS interventions. Data on effectiveness were extracted. Components of effective interventions were extracted and coded using the TDF, Behaviour Change Wheel and Behaviour Change Techniques (BCTs) taxonomy. Using prespecified matrices, we assessed the extent to which BCTs and intervention functions addressed the key TDF domains of influences on prescribing. RESULTS We identified 13 qualitative studies, 41 types of influences on antibiotic prescribing and 6 key TDF domains of influences: 'beliefs about consequences', 'social influences', 'skills', 'environmental context and resources', 'intentions' and 'emotions'. We identified 17 research-tested AMS interventions; nine of them effective and four nationally implemented. Interventions addressed all six key TDF domains of influences. Four of these six key TDF domains were addressed by 50%-67% BCTs that were theoretically congruent with these domains, whereas TDF domain 'skills' was addressed by 24% of congruent BCTs and 'emotions' by none. CONCLUSIONS Further improvement of antibiotic prescribing could be facilitated by: (1) national implementation of effective research-tested AMS interventions (eg, electronic decision support tools, training in interactive use of leaflets, point-of-care testing); (2) targeting important, less-addressed TDF domains (eg, 'skills', 'emotions'); (3) using relevant, under-used BCTs to target key TDF domains (eg, 'forming/reversing habits', 'reducing negative emotions', 'social support'). These could be incorporated into existing, or developed as new, AMS interventions.
Collapse
Affiliation(s)
- Aleksandra J Borek
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Marta Wanat
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Louise Atkins
- Centre for Behaviour Change, University College London, London, UK
| | - Anna Sallis
- Behavioural Insights, Public Health England, London, UK
| | - Diane Ashiru-Oredope
- Antimicrobial Resistance and Stewardship and Healthcare Associated Infections (HCAI), Public Health England, London, UK
| | | | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Tim Chadborn
- Behavioural Insights, Public Health England, London, UK
| | - Susan Hopkins
- Antimicrobial Resistance and Stewardship and Healthcare Associated Infections (HCAI), Public Health England, London, UK
| | - Leah Jones
- Primary Care and Interventions Unit, Public Health England, Gloucester, UK
| | | | - Nia Roberts
- Bodleian Health Care Libraries, University of Oxford, Oxford, UK
| | - Karen Shaw
- Antimicrobial Resistance and Stewardship and Healthcare Associated Infections (HCAI), Public Health England, London, UK
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Esther Taborn
- NHS England and NHS Improvement, London, UK
- NHS East Kent Clinical Commissioning Groups, Canterbury, UK
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| |
Collapse
|
49
|
Akhtar A, Khan AH, Zainal H, Ahmad Hassali MA, Ali I, Ming LC. Physicians' Perspective on Prescribing Patterns and Knowledge on Antimicrobial Use and Resistance in Penang, Malaysia: A Qualitative Study. Front Public Health 2020; 8:601961. [PMID: 33324603 PMCID: PMC7724042 DOI: 10.3389/fpubh.2020.601961] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 10/27/2020] [Indexed: 12/02/2022] Open
Abstract
Background: Unnecessary antimicrobial use is an emerging problem throughout the world. To design future interventions to ensure rational antimicrobial use and decrease the risk of antimicrobial resistance, physician's knowledge and prescribing practices of antimicrobials should be assessed. Therefore, the main objective of this study is to investigate the physician's knowledge along with their prescribing patterns of antimicrobials in their health care system. Methods: The present qualitative study was conducted in a tertiary care public hospital located at Penang island, situated in Northwest of Malaysia. A total of 12 semi-structured, face to face interviews were conducted with purposive sampling technique. Physicians recruited had different specialties. All interviews were audio recorded, then transcribed into English language and analyze by thematic content analysis. Results: Four major themes were identified: (1) prescribing patterns of physicians regarding antimicrobials; (2) physician's knowledge about antimicrobials; (3) antimicrobial resistance; (4) satisfaction with management of infections. Physicians believed in regular educational activities and updates about the latest antimicrobial guidelines may change the prescribing behavior of physicians to optimize the use of antimicrobials. This may lead to decrease in burden of antimicrobial resistance in their health care system. Physicians emphasized that stricter rules and regular monitoring of antimicrobial use should be implemented to overcome the main challenges of antimicrobial resistance. Conclusion: Different factors were identified to assist optimized use of antimicrobials and decrease the risk of antimicrobial resistance. The present study helps to design targeted future interventions to ensure rational antimicrobial use and decrease the impact of antimicrobial resistance in Malaysia.
Collapse
Affiliation(s)
- Ali Akhtar
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, George Town, Malaysia
| | - Amer Hayat Khan
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, George Town, Malaysia
| | - Hadzliana Zainal
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, George Town, Malaysia
| | - Mohamed Azmi Ahmad Hassali
- Discipline of Social and Administrative Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, George Town, Malaysia
| | - Irfhan Ali
- Senior Consultant, Hospital Pulau Pinang, George Town, Malaysia
| | - Long Chiau Ming
- Pengiran Anak Puteri Rashidah Sa'adatul Bolkiah (PAPRSB) Institute of Health Sciences, Universiti Brunei Darussalam, Gadong, Brunei Darussalam
| |
Collapse
|
50
|
Hawes LA, Bishop J, Buising K, Mazza D. Feasibility and Validity of a Framework for Antimicrobial Stewardship in General Practice: Key Stakeholder Interviews. Antibiotics (Basel) 2020; 9:E900. [PMID: 33322126 PMCID: PMC7764540 DOI: 10.3390/antibiotics9120900] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 12/03/2020] [Accepted: 12/10/2020] [Indexed: 11/26/2022] Open
Abstract
There is little guidance about developing systems for antimicrobial stewardship (AMS) for general practice. A literature review identified six key components: governance, monitoring of antibiotic prescribing and resistance with feedback to prescribers, consultation support, education of the public and general practitioners, pharmacist and nurse involvement, and research, which were incorporated into a potential framework for the general practice context. Objectives: to determine the feasibility and validity of the proposed AMS framework. A secondary objective was to identify likely bodies responsible for implementation in Australia. We undertook interviews with 12 key stakeholders from government, research, and professional groups. Data were analysed with a thematic approach. The framework was considered valid and feasible. No clear organisation was identified to lead AMS implementation in general practice. The current volume-based antibiotic prescription monitoring system was considered insufficient. AMS education for the public, further development of GP education, and improved consultation support were strongly recommended. The role of community-based pharmacists and nurses is largely unexplored, but their involvement was recommended. A clear leader to drive AMS in general practice is essential for an action framework to gain traction. Monitoring and feedback of antibiotic prescribing require urgent development to include monitoring of prescribing appropriateness and patient outcomes.
Collapse
Affiliation(s)
- Lesley A. Hawes
- Department of General Practice, School of Primary and Allied Health Care, Monash University, Level 1, 270 Ferntree Gully Road, Notting Hill, Victoria 3168, Australia;
- National Centre for Antimicrobial Stewardship, The Peter Doherty Institute for Infection and Immunity, University of Melbourne, Level 5, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia; (J.B.); (K.B.)
| | - Jaclyn Bishop
- National Centre for Antimicrobial Stewardship, The Peter Doherty Institute for Infection and Immunity, University of Melbourne, Level 5, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia; (J.B.); (K.B.)
- Department of Medicine—Royal Melbourne Hospital, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Royal Parade, Melbourne, Victoria 3050, Australia
- Pharmacy Department, Ballarat Health Services, Drummond Street, Ballarat, Victoria 3350, Australia
| | - Kirsty Buising
- National Centre for Antimicrobial Stewardship, The Peter Doherty Institute for Infection and Immunity, University of Melbourne, Level 5, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia; (J.B.); (K.B.)
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, 300 Grattan St, Parkville, Victoria 3050, Australia
- Department of Infectious Diseases, Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, Victoria 3010, Australia
| | - Danielle Mazza
- Department of General Practice, School of Primary and Allied Health Care, Monash University, Level 1, 270 Ferntree Gully Road, Notting Hill, Victoria 3168, Australia;
- National Centre for Antimicrobial Stewardship, The Peter Doherty Institute for Infection and Immunity, University of Melbourne, Level 5, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia; (J.B.); (K.B.)
| |
Collapse
|