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Kien C, Daxenbichler J, Titscher V, Baenziger J, Klingenstein P, Naef R, Klerings I, Clack L, Fila J, Sommer I. Effectiveness of de-implementation of low-value healthcare practices: an overview of systematic reviews. Implement Sci 2024; 19:56. [PMID: 39103927 DOI: 10.1186/s13012-024-01384-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 07/12/2024] [Indexed: 08/07/2024] Open
Abstract
BACKGROUND Reducing low-value care (LVC) is crucial to improve the quality of patient care while increasing the efficient use of scarce healthcare resources. Recently, strategies to de-implement LVC have been mapped against the Expert Recommendation for Implementing Change (ERIC) compilation of strategies. However, such strategies' effectiveness across different healthcare practices has not been addressed. This overview of systematic reviews aimed to investigate the effectiveness of de-implementation initiatives and specific ERIC strategy clusters. METHODS We searched MEDLINE (Ovid), Epistemonikos.org and Scopus (Elsevier) from 1 January 2010 to 17 April 2023 and used additional search strategies to identify relevant systematic reviews (SRs). Two reviewers independently screened abstracts and full texts against a priori-defined criteria, assessed the SR quality and extracted pre-specified data. We created harvest plots to display the results. RESULTS Of 46 included SRs, 27 focused on drug treatments, such as antibiotics or opioids, twelve on laboratory tests or diagnostic imaging and seven on other healthcare practices. In categorising de-implementation strategies, SR authors applied different techniques: creating self-developed strategies (n = 12), focussing on specific de-implementation strategies (n = 14) and using published taxonomies (n = 12). Overall, 15 SRs provided evidence for the effectiveness of de-implementation interventions to reduce antibiotic and opioid utilisation. Reduced utilisation, albeit inconsistently significant, was documented in the use of antipsychotics and benzodiazepines, as well as in laboratory tests and diagnostic imaging. Strategies within the adapt and tailor to context, develop stakeholder interrelationships, and change infrastructure and workflow ERIC clusters led to a consistent reduction in LVC practices. CONCLUSION De-implementation initiatives were effective in reducing medication usage, and inconsistent significant reductions were observed for LVC laboratory tests and imaging. Notably, de-implementation clusters such as change infrastructure and workflow and develop stakeholder interrelationships emerged as the most encouraging avenues. Additionally, we provided suggestions to enhance SR quality, emphasising adherence to guidelines for synthesising complex interventions, prioritising appropriateness of care outcomes, documenting the development process of de-implementation initiatives and ensuring consistent reporting of applied de-implementation strategies. REGISTRATION OSF Open Science Framework 5ruzw.
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Affiliation(s)
- Christina Kien
- Department for Evidence-based Medicine and Evaluation, University for Continuing Education Krems (Danube University Krems), Dr.-Karl-Dorrek Straße 30, 3500, Krems a.d. Donau, Austria.
| | - Julia Daxenbichler
- Department for Evidence-based Medicine and Evaluation, University for Continuing Education Krems (Danube University Krems), Dr.-Karl-Dorrek Straße 30, 3500, Krems a.d. Donau, Austria
| | - Viktoria Titscher
- Department for Evidence-based Medicine and Evaluation, University for Continuing Education Krems (Danube University Krems), Dr.-Karl-Dorrek Straße 30, 3500, Krems a.d. Donau, Austria
| | - Julia Baenziger
- Institute for Implementation Science in Health Care, University of Zurich, Universitätstrasse 84, 8006, Zurich, Switzerland
| | - Pauline Klingenstein
- Department for Evidence-based Medicine and Evaluation, University for Continuing Education Krems (Danube University Krems), Dr.-Karl-Dorrek Straße 30, 3500, Krems a.d. Donau, Austria
| | - Rahel Naef
- Institute for Implementation Science in Health Care, University of Zurich, Universitätstrasse 84, 8006, Zurich, Switzerland
- Centre of Clinical Nursing Science, University Hospital of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Irma Klerings
- Department for Evidence-based Medicine and Evaluation, University for Continuing Education Krems (Danube University Krems), Dr.-Karl-Dorrek Straße 30, 3500, Krems a.d. Donau, Austria
| | - Lauren Clack
- Institute for Implementation Science in Health Care, University of Zurich, Universitätstrasse 84, 8006, Zurich, Switzerland
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital of Zurich, Rämistrasse 100, Zurich, 8091, Switzerland
| | - Julian Fila
- Department for Evidence-based Medicine and Evaluation, University for Continuing Education Krems (Danube University Krems), Dr.-Karl-Dorrek Straße 30, 3500, Krems a.d. Donau, Austria
| | - Isolde Sommer
- Department for Evidence-based Medicine and Evaluation, University for Continuing Education Krems (Danube University Krems), Dr.-Karl-Dorrek Straße 30, 3500, Krems a.d. Donau, Austria
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Wushouer H, Yu J, Du K, Ko W, Li W, Zhang K, Chen S, Zheng B, Shi L, Guan X. Evaluation of appropriateness of antibiotic prescribing in primary healthcare institutions in China using proxy indicator. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2024; 49:101132. [PMID: 39056089 PMCID: PMC11269779 DOI: 10.1016/j.lanwpc.2024.101132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 05/10/2024] [Accepted: 06/17/2024] [Indexed: 07/28/2024]
Abstract
Background Our objectives were to develop a set of proxy indicators (PIs) suited for assessing antibiotic use appropriateness in China's primary healthcare institutions (PHIs), and assess performance scores of these PIs while exploring factors that influence the antibiotic appropriateness. Methods We selected potential PIs for the PHIs through a RAND-modified Delphi procedure, and assessed clinimetric properties, focusing on measurability, applicability, and potential for improvement. PIs with favorable clinimetric properties were used to evaluate antibiotic prescription appropriateness by calculating performance scores of each PI. Institutions were categorized into three clusters representing different levels of appropriateness. We used the chi-square test and an ordinal logistic regression model at PHI level to explore factors influencing antibiotic appropriateness. Findings Eighteen PIs were developed through two rounds of online surveys and one face-to-face meeting involving 20 stakeholders. All PIs met the clinimetric properties criteria and were used to analyze 209,662 antibiotic prescriptions across 269 PHIs. The percentage of PHIs meeting the target ranged from 3.1% to 69.3%, with 6 PIs below 10%. The appropriateness of antibiotic prescriptions was significantly associated with percentages of patients' gender of the PHIs. Interpretation The varied and suboptimal performance of the PIs indicated the need for diverse efforts to enhance the rational antibiotic use at PHI level. It was necessary to devise distinct sets of PIs for diverse settings in future endeavors. Funding This work was supported by the National Natural Science Foundation of China (grant numbers 72374009, 81973294).
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Affiliation(s)
- Haishaerjiang Wushouer
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, 100191, China
- International Research Center for Medicinal Administration (IRCMA), Peking University, Beijing, 100191, China
| | - Junxuan Yu
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, 100191, China
| | - Kexin Du
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, 100191, China
| | - Weihsin Ko
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, 100191, China
| | - Weibin Li
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, 100191, China
| | - Kairui Zhang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, 100191, China
| | - Shuo Chen
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, 100191, China
| | - Bo Zheng
- Institute of Clinical Pharmacology, Peking University First Hospital, Beijing, 100034, China
| | - Luwen Shi
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, 100191, China
- International Research Center for Medicinal Administration (IRCMA), Peking University, Beijing, 100191, China
| | - Xiaodong Guan
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, 100191, China
- International Research Center for Medicinal Administration (IRCMA), Peking University, Beijing, 100191, China
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Guo H, Lye DC, Ng TM, Somani J, Kwa ALH, Chung SJ, Chow A. Hospitalised patients as stewards of their own antibiotic therapy: a qualitative analysis informing the strategic design of interventions to encourage shared decision-making in tertiary hospital settings in Singapore. Front Public Health 2024; 12:1347764. [PMID: 39145162 PMCID: PMC11322571 DOI: 10.3389/fpubh.2024.1347764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 07/22/2024] [Indexed: 08/16/2024] Open
Abstract
Background Shared decision-making (SDM) on antibiotic therapy may improve antibiotic use in tertiary hospitals, but hospitalised patients are apprehensive about being involved in it. Understanding the facilitators and barriers to SDM can inform the design and implementation of interventions to empower these patients to engage in SDM on their antibiotic therapies. Methods We conducted qualitative interviews with 23 adult patients purposively sampled with maximum variation from the three largest tertiary-care hospitals in Singapore (April 2019─October 2020). Thematic analysis was conducted using the Theoretical Domains Framework and Capability, Opportunity, Motivation, Behaviour (COM-B) model to identify areas for intervention. Results Hospitalised patients lacked comprehensive knowledge of their antibiotic therapies and the majority did not have the skills to actively query their doctors about them. There was a lack of opportunities to meet and interact with doctors, and patients were less motivated to engage in SDM if they had a self-perceived paternalistic relationship with doctors, trusted their doctors to provide the best treatment, and had self-perceived poor knowledge to engage in SDM. To empower these patients, they should first be educated with antibiotic knowledge. Highlighting potential side effects of antibiotics could motivate them to ask questions about their antibiotic therapies. Environment restructuring, as facilitated by nurses and visual cues to nudge conversations, could create opportunities for interactions and motivating patients into SDM on their antibiotic therapies. Conclusion Education and environmental restructuring should be explored to empower hospitalised patients to engage in SDM on their antibiotic therapies.
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Affiliation(s)
- Huiling Guo
- Department of Preventive and Population Medicine, Office of Clinical Epidemiology, Analytics, and Knowledge, Tan Tock Seng Hospital, Singapore, Singapore
| | - David Chien Lye
- Infectious Disease Research and Training Office, National Centre for Infectious Diseases, Singapore, Singapore
- Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Tat Ming Ng
- Department of Pharmacy, Tan Tock Seng Hospital, Singapore, Singapore
| | - Jyoti Somani
- Division of Infectious Diseases, National University Hospital, Singapore, Singapore
| | - Andrea Lay Hoon Kwa
- Department of Pharmacy, Singapore General Hospital, Singapore, Singapore
- Programme in Emerging Infectious Diseases, Duke-NUS Medical School, Singapore, Singapore
| | - Shimin Jasmine Chung
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Infectious Diseases, Singapore 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
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
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Llor C, Plate A, Bjerrum L, Gentile I, Melbye H, Staiano A, van Hecke O, Verbakel JY, Hopstaken R. C-reactive protein point-of-care testing in primary care-broader implementation needed to combat antimicrobial resistance. Front Public Health 2024; 12:1397096. [PMID: 39100952 PMCID: PMC11294078 DOI: 10.3389/fpubh.2024.1397096] [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: 03/11/2024] [Accepted: 06/27/2024] [Indexed: 08/06/2024] Open
Abstract
This study presents the perspective of an international group of experts, providing an overview of existing models and policies and guidance to facilitate a proper and sustainable implementation of C-reactive protein point-of-care testing (CRP POCT) to support antibiotic prescribing decisions for respiratory tract infections (RTIs) with the aim to tackle antimicrobial resistance (AMR). AMR threatens to render life-saving antibiotics ineffective and is already costing millions of lives and billions of Euros worldwide. AMR is strongly correlated with the volume of antibiotics used. Most antibiotics are prescribed in primary care, mostly for RTIs, and are often unnecessary. CRP POCT is an available tool and has been proven to safely and cost-effectively reduce antibiotic prescribing for RTIs in primary care. Though established in a few European countries during several years, it has still not been implemented in many European countries. Due to the complexity of inappropriate antibiotic prescribing behavior, a multifaceted approach is necessary to enable sustainable change. The effect is maximized with clear guidance, advanced communication training for primary care physicians, and delayed antibiotic prescribing strategies. CRP POCT should be included in professional guidelines and implemented together with complementary strategies. Adequate reimbursement needs to be provided, and high-quality, and primary care-friendly POCT organization and performance must be enabled. Data gathering, sharing, and discussion as incentivization for proper behaviors should be enabled. Public awareness should be increased, and healthcare professionals' awareness and understanding should be ensured. Impactful use is achieved when all stakeholders join forces to facilitate proper implementation.
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Affiliation(s)
- Carl Llor
- Department of Public Health and Primary Care, University of Southern Denmark, Odense, Denmark
- Via Roma Health Center, Catalonian Institute of Health, Barcelona, Spain
| | - Andreas Plate
- Institute of Primary Care, University and University Hospital Zurich, Zurich, Switzerland
| | - Lars Bjerrum
- Center for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Ivan Gentile
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Naples, Italy
| | - Hasse Melbye
- General Practice Research Unit, Department of Community Medicine, The Arctic University of Norway, Tromso, Norway
| | - Annamaria Staiano
- Department of Translational Medical Sciences, University of Naples “Federico II”, Naples, Italy
| | - Oliver van Hecke
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Jan Y. Verbakel
- NIHR Community Healthcare Medtech and IVD Cooperative, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
- LUHTAR, Department of Public Health and Primary Care, Academisch Centrum voor Huisartsgeneeskunde, Leuven & NIHR Community Healthcare Medtech and IVD Cooperative, Leuven, Belgium
| | - Rogier Hopstaken
- GP Practice De Kuil, Hapert, Netherlands
- Department of General Practice, CAPHRI School for Public Health and Primary Care, Maastricht University Medical Center, Maastricht, Netherlands
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Soucy JPR, Low M, Acharya KR, Ellen M, Hulth A, Löfmark S, Garber GE, Watson W, Moran-Gilad J, Davidovitch N, Amar T, McCready J, Orava M, Brownstein JS, Brown KA, Fisman DN, MacFadden DR. Evaluation of an automated feedback intervention to improve antibiotic prescribing among primary care physicians (OPEN Stewardship): a multinational controlled interrupted time-series study. Microbiol Spectr 2024; 12:e0001724. [PMID: 38411087 PMCID: PMC10986525 DOI: 10.1128/spectrum.00017-24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 02/06/2024] [Indexed: 02/28/2024] Open
Abstract
Tools to advance antimicrobial stewardship in the primary health care setting, where most antimicrobials are prescribed, are urgently needed. The aim of this study was to evaluate OPEN Stewarship (Online Platform for Expanding aNtibiotic Stewardship), an automated feedback intervention, among a cohort of primary care physicians. We performed a controlled, interrupted time-series study of 32 intervention and 725 control participants, consisting of primary care physicians from Ontario, Canada and Southern Israel, from October 2020 to December 2021. Intervention participants received three personalized feedback reports targeting several aspects of antibiotic prescribing. Study outcomes (overall prescribing rate, prescribing rate for viral respiratory conditions, prescribing rate for acute sinusitis, and mean duration of therapy) were evaluated using multilevel regression models. We observed a decrease in the mean duration of antibiotic therapy (IRR = 0.94; 95% CI: 0.90, 0.99) in intervention participants during the intervention period. We did not observe a significant decline in overall antibiotic prescribing (OR = 1.01; 95% CI: 0.94, 1.07), prescribing for viral respiratory conditions (OR = 0.87; 95% CI: 0.73, 1.03), or prescribing for acute sinusitis (OR = 0.85; 95% CI: 0.67, 1.07). In this antimicrobial stewardship intervention among primary care physicians, we observed shorter durations of therapy per antibiotic prescription during the intervention period. The COVID-19 pandemic may have hampered recruitment; a dramatic reduction in antibiotic prescribing rates in the months before our intervention may have made physicians less amenable to further reductions in prescribing, limiting the generalizability of the estimates obtained.IMPORTANCEAntibiotic overprescribing contributes to antibiotic resistance, a major threat to our ability to treat infections. We developed the OPEN Stewardship (Online Platform for Expanding aNtibiotic Stewardship) platform to provide automated feedback on antibiotic prescribing in primary care, where most antibiotics for human use are prescribed but where the resources to improve antibiotic prescribing are limited. We evaluated the platform among a cohort of primary care physicians from Ontario, Canada and Southern Israel from October 2020 to December 2021. The results showed that physicians who received personalized feedback reports prescribed shorter courses of antibiotics compared to controls, although they did not write fewer antibiotic prescriptions. While the COVID-19 pandemic presented logistical and analytical challenges, our study suggests that our intervention meaningfully improved an important aspect of antibiotic prescribing. The OPEN Stewardship platform stands as an automated, scalable intervention for improving antibiotic prescribing in primary care, where needs are diverse and technical capacity is limited.
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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 R. Acharya
- Department of Population Medicine, University of Guelph Ontario Veterinary College, Guelph, Ontario, Canada
| | - Moriah Ellen
- 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
| | - Anette Hulth
- The Public Health Agency of Sweden, Stockholm, Sweden
| | - Sonja Löfmark
- The Public Health Agency of Sweden, Stockholm, Sweden
| | | | - William Watson
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jacob Moran-Gilad
- Department of Health Policy and Management, School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Nadav Davidovitch
- 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
| | - Tamar Amar
- Department of Epidemiology, Biostatistics, and Community Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Janine McCready
- Division of Infectious Diseases, Department of Medicine, Michael Garron Hospital, Toronto, Ontario, Canada
| | - Matthew Orava
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Barrie and Community Family Health Team, Barrie, Ontario, Canada
| | - John S. Brownstein
- Computational Epidemiology Lab, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Kevin A. Brown
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Public Health Ontario, Toronto, Ontario, Canada
| | - 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
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Plate A, Di Gangi S, Garzoni C, Selby K, Pichierri G, Senn O, Neuner-Jehle S. Patient leaflets on respiratory tract infections did not improve shared decision making and antibiotic prescriptions in a low-prescriber setting. Sci Rep 2024; 14:4978. [PMID: 38424442 PMCID: PMC10904372 DOI: 10.1038/s41598-024-55166-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 02/21/2024] [Indexed: 03/02/2024] Open
Abstract
Patient information leaflets can reduce antibiotic prescription rates by improving knowledge and encouraging shared decision making (SDM) in patients with respiratory tract infections (RTI). The effect of these interventions in antibiotic low-prescriber settings is unknown. We conducted a pragmatic pre-/post interventional study between October 2022 and March 2023 in Swiss outpatient care. The intervention was the provision of patient leaflets informing about RTIs and antibiotics use. Main outcomes were the extent of SDM, antibiotic prescription rates, and patients' awareness/knowledge about antibiotic use in RTIs. 408 patients participated in the pre-intervention period, and 315 patients in the post- intervention period. There was no difference in the extent of SDM (mean score (range 0-100): 65.86 vs. 64.65, p = 0.565), nor in antibiotic prescription rates (no prescription: 89.8% vs. 87.2%, p = 0.465) between the periods. Overall awareness/knowledge among patients with RTI was high and leaflets showed only a small effect on overall awareness/knowledge. In conclusion, in an antibiotic low-prescriber setting, patient information leaflets may improve knowledge, but may not affect treatment decisions nor antibiotic prescription rates for RTIs.
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Affiliation(s)
- Andreas Plate
- Institute of Primary Care, University of Zurich and University Hospital Zürich, Pestalozzistrasse 24, 8091, Zurich, Switzerland.
| | - Stefania Di Gangi
- Institute of Primary Care, University of Zurich and University Hospital Zürich, Pestalozzistrasse 24, 8091, Zurich, Switzerland
| | - Christian Garzoni
- mediX Ticino and Clinic of Internal Medicine and Infectious Diseases, Clinica Luganese Moncucco, Lugano, Switzerland
| | - Kevin Selby
- Center for Primary Care and Public Health (Unisanté), Lausanne, Switzerland
| | - Giuseppe Pichierri
- Institute of Primary Care, University of Zurich and University Hospital Zürich, Pestalozzistrasse 24, 8091, Zurich, Switzerland
| | - Oliver Senn
- Institute of Primary Care, University of Zurich and University Hospital Zürich, Pestalozzistrasse 24, 8091, Zurich, Switzerland
| | - Stefan Neuner-Jehle
- Institute of Primary Care, University of Zurich and University Hospital Zürich, Pestalozzistrasse 24, 8091, Zurich, Switzerland
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Christensen LD, Vestergaard CH, Keizer E, Bech BH, Bro F, Christensen MB, Huibers L. Point-of-care testing and antibiotics prescribing in out-of-hours general practice: a register-based study in Denmark. BMC PRIMARY CARE 2024; 25:31. [PMID: 38262975 PMCID: PMC10804570 DOI: 10.1186/s12875-024-02264-0] [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: 07/08/2022] [Accepted: 01/02/2024] [Indexed: 01/25/2024]
Abstract
BACKGROUND Point-of-care testing may reduce diagnostic uncertainty in case of suspicion of bacterial infection, thereby contributing to prudent antibiotic prescribing. We aimed to study variations in the use of point-of-care tests (C-reactive protein test, rapid streptococcal antigen detection test, and urine dipstick) among general practitioners (GPs) and the potential association between point-of-care testing and antibiotic prescribing in out-of-hours general practice. METHODS We conducted a population-based observational register-based study, based on patient contacts with out-of-hours general practice in the Central Denmark Region in 2014-2017. The tendency of GPs to use point-of-care testing was calculated, and the association between the use of point-of-care testing and antibiotic prescribing was evaluated with the use of binomial regression. RESULTS Out-of-hours general practice conducted 794,220 clinic consultations from 2014 to 2017, of which 16.1% resulted in an antibiotic prescription. The GP variation in the use of point-of-care testing was largest for C-reactive protein tests, with an observed variation (p90/p10 ratio) of 3.0; this means that the GPs in the 90th percentile used C-reactive protein tests three times as often as the GPs in the 10th percentile. The observed variation was 2.1 for rapid streptococcal antigen detection tests and 1.9 for urine dipsticks. The GPs who tended to use more point-of-care tests prescribed significantly more antibiotics than the GPs who tended to use fewer point-of-care tests. The GPs in the upper quintile of the tendency to use C-reactive protein test prescribed 22% more antibiotics than the GPs in the lowest quintile (21% for rapid streptococcal antigen detection tests and 8% for urine dipsticks). Up through the quintiles, this effect exhibited a positive linear dose-response correlation. CONCLUSION The GPs varied in use of point-of-care testing. The GPs who tended to perform more point-of-care testing prescribed more antibiotics compared with the GPs who tended to perform fewer of these tests.
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Affiliation(s)
| | | | - Ellen Keizer
- Research Unit for General Practice, Bartholins Alle 2, 8000, Aarhus, Denmark
| | - Bodil Hammer Bech
- Department of Public Health, Aarhus University, Bartholins Alle 2, 8000, Aarhus, Denmark
| | - Flemming Bro
- Research Unit for General Practice, Bartholins Alle 2, 8000, Aarhus, Denmark
- Department of Public Health, Aarhus University, Bartholins Alle 2, 8000, Aarhus, Denmark
| | - Morten Bondo Christensen
- Research Unit for General Practice, Bartholins Alle 2, 8000, Aarhus, Denmark
- Department of Public Health, Aarhus University, Bartholins Alle 2, 8000, Aarhus, Denmark
| | - Linda Huibers
- Research Unit for General Practice, Bartholins Alle 2, 8000, Aarhus, Denmark
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Metusela C, Mullan J, Kobel C, Rhee J, Batterham M, Barnett S, Bonney A. CHIME-GP trial of online education for prescribing, pathology and imaging ordering in general practice - how did it bring about behaviour change? BMC Health Serv Res 2023; 23:1346. [PMID: 38042789 PMCID: PMC10693689 DOI: 10.1186/s12913-023-10374-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 11/23/2023] [Indexed: 12/04/2023] Open
Abstract
BACKGROUND There is a need for scalable clinician education in rational medication prescribing and rational ordering of pathology and imaging to help improve patient safety and enable more efficient utilisation of healthcare resources. Our wider study evaluated the effectiveness of a multifaceted education intervention for general practitioners (GPs) in rational prescribing and ordering of pathology and imaging tests, in the context of Australia's online patient-controlled health record system, My Health Record (MHR), and found evidence for measurable behaviour change in pathology ordering among participants who completed the educational activities. This current study explored the mechanisms of behaviour change brought about by the intervention, with a view to informing the development of similar interventions in the future. METHODS This mixed methods investigation used self-reported questionnaires at baseline and post-education on MHR use and rational prescribing and test ordering. These were analysed using multi-level ordinal logistic regression models. Semi-structured interviews pre- and post-intervention were also conducted and were analysed thematically using the COM-B framework. RESULTS Of the 106 GPs recruited into the study, 60 completed baseline and 37 completed post-education questionnaires. Nineteen participants were interviewed at baseline and completion. Analysis of questionnaires demonstrated a significant increase in confidence using MHR and in self-reported frequency of MHR use, post-education compared with baseline. There were also similar improvements in confidence across the cohort pre-post education in deprescribing, frequency of review of pathology ordering regimens and evidence-based imaging. The qualitative findings showed an increase in GPs' perceived capability with, and the use of MHR, at post-education compared with baseline. Participants saw the education as an opportunity for learning, for reinforcing what they already knew, and for motivating change of behaviour in increasing their utilisation of MHR, and ordering fewer unnecessary tests and prescriptions. CONCLUSIONS Our education intervention appeared to provide its effects through providing opportunity, increasing capability and enhancing motivation to increase MHR knowledge and usage, as well as rational prescribing and test ordering behaviour. There were overlapping effects of skills acquisition and confidence across intervention arms, which may have contributed to wider changes in behaviour than the specific topic area addressed in the education. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry (ACTRN12620000010998) (09/01/2020).
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Affiliation(s)
- Christine Metusela
- Graduate School of Medicine, University of Wollongong, Wollongong, Australia.
| | - Judy Mullan
- Graduate School of Medicine, University of Wollongong, Wollongong, Australia
| | - Conrad Kobel
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, Australia
| | - Joel Rhee
- School of Population Health, University of New South Wales, Sydney, Australia
| | - Marijka Batterham
- School of Mathematics and Applied Statistics, University of Wollongong, Wollongong, Australia
| | - Stephen Barnett
- Graduate School of Medicine, University of Wollongong, Wollongong, Australia
| | - Andrew Bonney
- Graduate School of Medicine, University of Wollongong, Wollongong, Australia
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Schmiemann G, Greser A, Maun A, Bleidorn J, Schuster A, Miljukov O, Rücker V, Klingeberg A, Mentzel A, Minin V, Eckmanns T, Heintze C, Heuschmann P, Gágyor I. Effects of a multimodal intervention in primary care to reduce second line antibiotic prescriptions for urinary tract infections in women: parallel, cluster randomised, controlled trial. BMJ 2023; 383:e076305. [PMID: 37918836 PMCID: PMC10620739 DOI: 10.1136/bmj-2023-076305] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/25/2023] [Indexed: 11/04/2023]
Abstract
OBJECTIVES To evaluate whether a multimodal intervention in general practice reduces the proportion of second line antibiotic prescriptions and the overall proportion of antibiotic prescriptions for uncomplicated urinary tract infections in women. DESIGN Parallel, cluster randomised, controlled trial. SETTING General practices in five regions in Germany. Data were collected between 1 April 2021 and 31 March 2022. PARTICIPANTS General practitioners from 128 randomly assigned practices. INTERVENTIONS Multimodal intervention consisting of guideline recommendations for general practitioners and patients, provision of regional data for antibiotic resistance, and quarterly feedback, which included individual first line and second line proportions of antibiotic prescribing, benchmarking with regional or supra-regional practices, and telephone counselling. Participants in the control group received no information on the intervention. MAIN OUTCOME MEASURES Primary outcome was the proportion of second line antibiotics prescribed by general practices, in relation to all antibiotics prescribed, for uncomplicated urinary tract infections after one year between the intervention and control group. General practices were randomly assigned in blocks (1:1), with a block size of four, into the intervention or control group using SAS version 9.4; randomisation was stratified by region. The secondary outcome was the prescription proportion of all antibiotics, relative within all cases (instances of UTI diagnosis), for the treatment of urinary tract infections after one year between the groups. Adverse events were assessed as exploratory outcomes. RESULTS 110 practices with full datasets identified 10 323 cases during five quarters (ie, 15 months). The mean proportion of second line antibiotics prescribed was 0.19 (standard deviation 0.20) in the intervention group and 0.35 (0.25) in the control group after 12 months. After adjustment for preintervention proportions, the mean difference was -0.13 (95% confidence interval -0.21 to -0.06, P<0.001). The overall proportion of all antibiotic prescriptions for urinary tract infections over 12 months was 0.74 (standard deviation 0.22) in the intervention and 0.80 (0.15) in the control group with a mean difference of -0.08 (95% confidence interval -0.15 to -0.02, P<0.029). No differences were noted in the number of complications (ie, pyelonephritis, admission to hospital, or fever) between the groups. CONCLUSIONS The multimodal intervention in general practice significantly reduced the proportion of second line antibiotics and all antibiotic prescriptions for uncomplicated urinary tract infections in women. TRIAL REGISTRATION German Clinical Trials Register (DRKS), DRKS00020389.
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Affiliation(s)
- Guido Schmiemann
- University of Bremen, Department of Health Services Research, Institute for Public Health and Nursing Research, Bremen, Germany
| | - Alexandra Greser
- University Hospital Wurzburg, Department of General Practice, Wurzburg, Germany
| | - Andy Maun
- Institute of General Practice/Primary Care, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
| | - Jutta Bleidorn
- University Hospital Jena, Institute of General Practice, Jena, Thuringia, Germany
| | - Angela Schuster
- Charité-Universitätsmedizin Berlin, Institute of General Practice and Family Medicine, Berlin, Germany
| | - Olga Miljukov
- Clinical Trial Centre Wurzburg, University Hospital Wurzburg, Germany
- Institute for Medical Data Sciences, University Hospital Wurzburg, Germany
- Julius-Maximilians-University of Wurzburg, Institute for Clinical Epidemiology and Biometry (ICE-B), Wurzburg, Germany
| | - Viktoria Rücker
- Clinical Trial Centre Wurzburg, University Hospital Wurzburg, Germany
- Institute for Medical Data Sciences, University Hospital Wurzburg, Germany
- Julius-Maximilians-University of Wurzburg, Institute for Clinical Epidemiology and Biometry (ICE-B), Wurzburg, Germany
| | | | - Anja Mentzel
- Institute of General Practice/Primary Care, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
| | - Vitalii Minin
- Institute of General Practice/Primary Care, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
| | | | - Christoph Heintze
- Charité-Universitätsmedizin Berlin, Institute of General Practice and Family Medicine, Berlin, Germany
| | - Peter Heuschmann
- Clinical Trial Centre Wurzburg, University Hospital Wurzburg, Germany
- Institute for Medical Data Sciences, University Hospital Wurzburg, Germany
- Julius-Maximilians-University of Wurzburg, Institute for Clinical Epidemiology and Biometry (ICE-B), Wurzburg, Germany
| | - Ildikó Gágyor
- University Hospital Wurzburg, Department of General Practice, Wurzburg, Germany
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Staiano A, Bjerrum L, Llor C, Melbye H, Hopstaken R, Gentile I, Plate A, van Hecke O, Verbakel JY. C-reactive protein point-of-care testing and complementary strategies to improve antibiotic stewardship in children with acute respiratory infections in primary care. Front Pediatr 2023; 11:1221007. [PMID: 37900677 PMCID: PMC10602801 DOI: 10.3389/fped.2023.1221007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 09/25/2023] [Indexed: 10/31/2023] Open
Abstract
This paper provides the perspective of an international group of experts on the role of C-reactive protein (CRP) point-of-care testing (POCT) and complementary strategies such as enhanced communication skills training and delayed prescribing to improve antibiotic stewardship in the primary care of children presenting with an acute illness episode due to an acute respiratory tract infection (ARTI). To improve antibiotics prescribing decisions, CRP POCT should be considered to complement the clinical assessment of children (6 months to 14 years) presenting with an ARTI in a primary care setting. CRP POCT can help decide whether a serious infection can be ruled out, before deciding on further treatments or management, when clinical assessment is unconclusive. Based on the evidence currently available, a CRP value can be a valuable support for clinical reasoning and facilitate communication with patients and parents, but the clinical assessment should prevail when making a therapy or referral decision. Nearly half of children tested in the primary care setting can be expected to have a CRP value below 20 mg/l, in which case it is strongly suggested to avoid prescribing antibiotics when the clinical assessment supports ruling out a severe infection. For children with CRP values greater than or equal to 20 mg/l, additional measures such as additional diagnostic tests, observation time, re-assessment by a senior decision-maker, and specialty referrals, should be considered.
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Affiliation(s)
- Annamaria Staiano
- Department of Translational Medical Sciences, University of Naples “Federico II”, Naples, Italy
| | - Lars Bjerrum
- Centre for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Carl Llor
- Department of Public Health and Primary Care, University of Southern Denmark, Odense, Denmark
| | - Hasse Melbye
- General Practice Research Unit, Department of Community Medicine, The Arctic University of Norway, Tromso, Norway
| | - Rogier Hopstaken
- Department of General Practice, CAPHRI School for Public Health and Primary Care, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Ivan Gentile
- Section of Infectious Diseases, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Andreas Plate
- Institute of Primary Care, University and University Hospital Zurich, Zurich, Switzerland
| | - Oliver van Hecke
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
- NIHR Community Healthcare Medtech and IVD Cooperative, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Jan Y. Verbakel
- NIHR Community Healthcare Medtech and IVD Cooperative, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
- EPI-Centre, Department of Public Health and Primary Care, Academisch Centrum Voor Huisartsgeneeskunde, Leuven & NIHR Community Healthcare Medtech and IVD cooperative, Leuven, Belgium
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11
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Cole J, Hughes C, Cadogan C, Vellinga A, Molloy G, Fahey T, Sheaf G, Maher A, Ryan C. Evidence for using point-of-care diagnostics in the management of respiratory tract infections in primary care: a scoping review protocol. HRB Open Res 2023; 6:59. [PMID: 38283945 PMCID: PMC10822039 DOI: 10.12688/hrbopenres.13770.1] [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] [Accepted: 08/14/2023] [Indexed: 01/30/2024] Open
Abstract
Background: Antimicrobial resistance (AmR) is widely considered a global health threat and is associated with significant morbidity, mortality and costs. Inappropriate antimicrobial use is the most important modifiable risk factor for AmR. Most human antimicrobial medicines use occurs in primary care [prescribed by general practitioners (GPs), dispensed by community pharmacists (CPs)]. However, up to 50% of use is deemed inappropriate. Point-of-care diagnostic tests are used as a basis for antimicrobial stewardship interventions to improve the diagnostic certainty of respiratory tract infections (RTIs), and therefore ensure prudent antimicrobial use. However, there is a lack of guidance on their use, and they are therefore not routinely used in clinical practice. Objective: A scoping review will be conducted to synthesise the available evidence to inform the development of best practice guidance for using point-of-care diagnostics in the management of RTIs in primary care. Methods: A scoping review will be conducted following guidance from the Joanna Briggs Institute (JBI) and reported using the PRISMA-ScR guidelines. Databases including Web of Science, MEDLINE, CINAHL, EMBASE, the International HTA database and the Cochrane Central Register of Controlled Trials, as well as grey literature, will be searched. Screening will be undertaken independently by two reviewers to identify studies and literature reporting the use of point-of-care diagnostics in the management of RTIs in primary care by GPs and/ or CPs. Findings will be described using narrative synthesis. Conclusion: The findings of this scoping review will be used to produce draft guidance on the use of point-of-care diagnostic tests in primary care, which will undergo further development using a Delphi consensus methodology involving experts in the field of RTIs, antimicrobial stewardship, point-of-care diagnostics and primary care.
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Affiliation(s)
- Judith Cole
- School of Pharmacy and Pharmaceutical Sciences, The University of Dublin, Trinity College, Dublin, Leinster, Ireland
| | - Carmel Hughes
- School of Pharmacy, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - Cathal Cadogan
- School of Pharmacy and Pharmaceutical Sciences, The University of Dublin, Trinity College, Dublin, Leinster, Ireland
| | - Akke Vellinga
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Leinster, Ireland
| | - Gerard Molloy
- School of Psychology, College of Arts, Social Sciences and Celtic Studies, University of Galway, Galway, County Galway, Ireland
| | - Tom Fahey
- Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Leinster, Ireland
| | - Greg Sheaf
- The University of Dublin Trinity College, Dublin, Leinster, Ireland
| | - Anthony Maher
- School of Psychology, College of Arts, Social Sciences and Celtic Studies, University of Galway, Galway, County Galway, Ireland
| | - Cristin Ryan
- School of Pharmacy and Pharmaceutical Sciences, The University of Dublin, Trinity College, Dublin, Leinster, Ireland
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12
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Mangin D, Lamarche L, Templeton JA, Salerno J, Siu H, Trimble J, Ali A, Varughese J, Page A, Etherton-Beer C. Theoretical Underpinnings of a Model to Reduce Polypharmacy and Its Negative Health Effects: Introducing the Team Approach to Polypharmacy Evaluation and Reduction (TAPER). Drugs Aging 2023; 40:857-868. [PMID: 37603255 PMCID: PMC10450010 DOI: 10.1007/s40266-023-01055-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2023] [Indexed: 08/22/2023]
Abstract
BACKGROUND Polypharmacy, particularly among older adults, is gaining recognition as an important risk to health. The harmful effects on health arise from disease-drug and drug-drug interactions, the cumulative burden of side effects from multiple medications and the burden to the patient. Single-disease clinical guidelines fail to consider the complex reality of optimising treatments for patients with multiple morbidities and medications. Efforts have been made to develop and implement interventions to reduce the risk of harmful effects, with some promising results. However, the theoretical basis (or pre-clinical work) that informed the development of these efforts, although likely undertaken, is unclear, difficult to find or inadequately described in publications. It is critical in interpreting effects and achieving effectiveness to understand the theoretical basis for such interventions. OBJECTIVE Our objective is to outline the theoretical underpinnings of the development of a new polypharmacy intervention: the Team Approach to Polypharmacy Evaluation and Reduction (TAPER). METHODS We examined deprescribing barriers at patient, provider, and system levels and mapped them to the chronic care model to understand the behavioural change requirements for a model to address polypharmacy. RESULTS Using the chronic care model framework for understanding the barriers, we developed a model for addressing polypharmacy. CONCLUSIONS We discuss how TAPER maps to address the specific patient-level, provider-level, and system-level barriers to deprescribing and aligns with three commonly used models and frameworks in medicine (the chronic care model, minimally disruptive medicine, the cumulative complexity model). We also describe how TAPER maps onto primary care principles, ultimately providing a description of the development of TAPER and a conceptualisation of the potential mechanisms by which TAPER reduces polypharmacy and its associated harms.
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Affiliation(s)
- Dee Mangin
- Department of Family Medicine, McMaster University, 100 Main Street West, Hamilton, ON, L8P 1H6, Canada.
- Department of General Practice, University of Otago, PO Box 4345, Christchurch, 8140, New Zealand.
| | - Larkin Lamarche
- School of Kinesiology and Health Science, York University, 4700 Keele Street, Toronto, ON, M3J 1P3, Canada
| | - Jeffrey A Templeton
- Department of Family Medicine, McMaster University, 100 Main Street West, Hamilton, ON, L8P 1H6, Canada
| | - Jennifer Salerno
- Department of Family Medicine, McMaster University, 100 Main Street West, Hamilton, ON, L8P 1H6, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L8, Canada
| | - Henry Siu
- Department of Family Medicine, McMaster University, 100 Main Street West, Hamilton, ON, L8P 1H6, Canada
| | - Johanna Trimble
- Patient Voices Network of BC, 201-750 Pender Street West, Vancouver, BC, V6C 2T8, Canada
| | - Abbas Ali
- Department of Family Medicine, McMaster University, 100 Main Street West, Hamilton, ON, L8P 1H6, Canada
| | - Jobin Varughese
- Department of Family Medicine, McMaster University, 100 Main Street West, Hamilton, ON, L8P 1H6, Canada
| | - Amy Page
- School of Allied Health, University of Western Australia, 35 Stirling Highway, Perth, WA, 6009, Australia
| | - Christopher Etherton-Beer
- Western Australia Centre for Health and Aging, School of Medicine, University of Western Australia, 35 Stirling Highway, Perth, WA, 6009, Australia
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13
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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: 1] [Impact Index Per Article: 1.0] [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.
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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
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14
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MacFadden DR, Maxwell C, Bowdish D, Bronskill S, Brooks J, Brown K, Burrows LL, Clarke A, Langford B, Leung E, Leung V, Manuel D, McGeer A, Mishra S, Morris AM, Nott C, Raybardhan S, Sapin M, Schwartz KL, So M, Soucy JPR, Daneman N. Coronavirus Disease 2019 Vaccination Is Associated With Reduced Outpatient Antibiotic Prescribing in Older Adults With Confirmed Severe Acute Respiratory Syndrome Coronavirus 2: A Population-Wide Cohort Study. Clin Infect Dis 2023; 77:362-370. [PMID: 36999314 PMCID: PMC10425187 DOI: 10.1093/cid/ciad190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 03/23/2023] [Accepted: 03/29/2023] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND Antibiotics are frequently prescribed unnecessarily in outpatients with coronavirus disease 2019 (COVID-19). We sought to evaluate factors associated with antibiotic prescribing in outpatients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. METHODS We performed a population-wide cohort study of outpatients aged ≥66 years with polymerase chain reaction-confirmed SARS-CoV-2 from 1 January 2020 to 31 December 2021 in Ontario, Canada. We determined rates of antibiotic prescribing within 1 week before (prediagnosis) and 1 week after (postdiagnosis) reporting of the positive SARS-CoV-2 result, compared to a self-controlled period (baseline). We evaluated predictors of prescribing, including a primary-series COVID-19 vaccination, in univariate and multivariable analyses. RESULTS We identified 13 529 eligible nursing home residents and 50 885 eligible community-dwelling adults with SARS-CoV-2 infection. Of the nursing home and community residents, 3020 (22%) and 6372 (13%), respectively, received at least 1 antibiotic prescription within 1 week of a SARS-CoV-2 positive result. Antibiotic prescribing in nursing home and community residents occurred, respectively, at 15.0 and 10.5 prescriptions per 1000 person-days prediagnosis and 20.9 and 9.8 per 1000 person-days postdiagnosis, higher than the baseline rates of 4.3 and 2.5 prescriptions per 1000 person-days. COVID-19 vaccination was associated with reduced prescribing in nursing home and community residents, with adjusted postdiagnosis incidence rate ratios (95% confidence interval) of 0.7 (0.4-1) and 0.3 (0.3-0.4), respectively. CONCLUSIONS Antibiotic prescribing was high and with little or no decline following SARS-CoV-2 diagnosis but was reduced in COVID-19-vaccinated individuals, highlighting the importance of vaccination and antibiotic stewardship in older adults with COVID-19.
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Affiliation(s)
- Derek R MacFadden
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Canada
- ICES, Toronto, Canada
- Division of Infectious Diseases, The Ottawa Hospital, Ottawa, Canada
| | - Colleen Maxwell
- ICES, Toronto, Canada
- Schools of Pharmacy and Public Health Sciences, University of Waterloo, Waterloo, Canada
| | - Dawn Bowdish
- Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | | | - James Brooks
- Division of Infectious Diseases, The Ottawa Hospital, Ottawa, Canada
| | - Kevin Brown
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Public Health Ontario, Toronto, Canada
| | - Lori L Burrows
- Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | | | - Bradley Langford
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Public Health Ontario, Toronto, Canada
| | - Elizabeth Leung
- Unity Health Toronto, Toronto, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Valerie Leung
- Public Health Ontario, Toronto, Canada
- Michael Garron Hospital, Toronto East Health Network, Toronto, Canada
| | | | | | - Sharmistha Mishra
- ICES, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
- MAP Centre for Urban Health Solutions, St. Michael's Hospital, Unity Health Toronto, Toronto, Canada
- Institute of Medical Science, University of Toronto, Toronto, Canada
| | | | - Caroline Nott
- Division of Infectious Diseases, The Ottawa Hospital, Ottawa, Canada
| | - Sumit Raybardhan
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Pharmacy Department, North York General Hospital, Toronto, Canada
| | - Mia Sapin
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Kevin L Schwartz
- ICES, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Public Health Ontario, Toronto, Canada
- Unity Health Toronto, Toronto, Canada
| | - Miranda So
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
- Toronto General Hospital Research Institute, Toronto, Canada
| | - Jean-Paul R Soucy
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Nick Daneman
- ICES, Toronto, Canada
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
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15
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Shah M, Fleming A, Barbosa TM, van der Velden AW, Parveen S, Vellinga A. Point prevalence audit surveys of respiratory tract infection consultations and antibiotic prescribing in primary care before and during the COVID-19 pandemic in Ireland. J Antimicrob Chemother 2023; 78:1270-1277. [PMID: 36974983 PMCID: PMC10154125 DOI: 10.1093/jac/dkad088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 03/09/2023] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND Respiratory tract infections (RTIs) are the most common reason for prescribing antibiotics in general practice. The COVID-19 pandemic has impacted on antibiotic prescribing and delivery of primary care in Ireland. OBJECTIVES To assess the quality of antibiotic prescribing, the impact of the COVID-19 pandemic and identify opportunities for antimicrobial stewardship (AMS) in Ireland. METHODS Point prevalence audit surveys for RTI consultations were conducted as part of a European study at three time periods: January-February 2020, March-May 2020 and March-May 2021. Antibiotic prescribing was assessed and comparisons made between the three time periods. RESULTS In total, 765 consultations were recorded, which were mainly face to face before the pandemic, but changed to predominantly remote consultations during the pandemic surveys in 2020 and 2021 (82% and 75%). Antibiotics were prescribed in 54% of RTI consultations before the pandemic. During pandemic surveys, this dropped to 23% in 2020 and 21% in 2021. There was a decrease in prescribing of Red (reserve) agents in 2021. Assessment against indication-specific quality indicators showed a high proportion of consultations for bronchitis and tonsillitis resulting in an antibiotic prescription (67% and 85%). Point-of-care testing (POCT) to aid diagnosis of RTIs were utilized in less than 1% of consultations. CONCLUSIONS During the COVID-19 pandemic, there was a reduction in antibiotic prescribing. Opportunities identified to support AMS in primary care in Ireland are targeted initiatives to reduce antibiotic prescribing for bronchitis and tonsillitis and introducing POCT to support appropriate antibiotic prescribing.
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Affiliation(s)
- M Shah
- Chief II Antimicrobial Pharmacist, Health Service Executive, Cork, Ireland
- Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, Cork, Ireland
| | - A Fleming
- Pharmacy Department, Mercy University Hospital, Grenville Place, Cork, Ireland
| | - T M Barbosa
- Pharmacy Department, Mercy University Hospital, Grenville Place, Cork, Ireland
| | - A W van der Velden
- Julius Center for Health Sciences and Primary Care, UMC Utrecht, Utrecht, Netherlands
| | - S Parveen
- School of Public Health, Physiotherapy and Sport Science, University College Dublin, Dublin, Ireland
| | - A Vellinga
- School of Public Health, Physiotherapy and Sport Science, University College Dublin, Dublin, Ireland
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16
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Hurley R, Jury F, van Staa TP, Palin V, Armitage CJ. Clinician acceptability of an antibiotic prescribing knowledge support system for primary care: a mixed-method evaluation of features and context. BMC Health Serv Res 2023; 23:367. [PMID: 37060063 PMCID: PMC10103677 DOI: 10.1186/s12913-023-09239-4] [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: 07/08/2022] [Accepted: 03/02/2023] [Indexed: 04/16/2023] Open
Abstract
BACKGROUND Overprescribing of antibiotics is a major concern as it contributes to antimicrobial resistance. Research has found highly variable antibiotic prescribing in (UK) primary care, and to support more effective stewardship, the BRIT Project (Building Rapid Interventions to optimise prescribing) is implementing an eHealth Knowledge Support System. This will provide unique individualised analytics information to clinicians and patients at the point of care. The objective of the current study was to gauge the acceptability of the system to prescribing healthcare professionals and highlight factors to maximise intervention uptake. METHODS Two mixed-method co-design workshops were held online with primary care prescribing healthcare professionals (n = 16). Usefulness ratings of example features were collected using online polls and online whiteboards. Verbal discussion and textual comments were analysed thematically using inductive (participant-centred) and deductive perspectives (using the Theoretical Framework of Acceptability). RESULTS Hierarchical thematic coding generated three overarching themes relevant to intervention use and development. Clinician concerns (focal issues) were safe prescribing, accessible information, autonomy, avoiding duplication, technical issues and time. Requirements were ease and efficiency of use, integration of systems, patient-centeredness, personalisation, and training. Important features of the system included extraction of pertinent information from patient records (such as antibiotic prescribing history), recommended actions, personalised treatment, risk indicators and electronic patient communication leaflets. Anticipated acceptability and intention to use the knowledge support system was moderate to high. Time was identified as a focal cost/ burden, but this would be outweighed if the system improved patient outcomes and increased prescribing confidence. CONCLUSION Clinicians anticipate that an eHealth knowledge support system will be a useful and acceptable way to optimise antibiotic prescribing at the point of care. The mixed method workshop highlighted issues to assist person-centred eHealth intervention development, such as the value of communicating patient outcomes. Important features were identified including the ability to efficiently extract and summarise pertinent information from the patient records, provide explainable and transparent risk information, and personalised information to support patient communication. The Theoretical Framework of Acceptability enabled structured, theoretically sound feedback and creation of a profile to benchmark future evaluations. This may encourage a consistent user-focused approach to guide future eHealth intervention development.
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Affiliation(s)
- Ruth Hurley
- Manchester Centre for Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK.
| | - Francine Jury
- Centre for Health Informatics, Division of Informatics, Imaging and Data Science, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Tjeerd P van Staa
- Centre for Health Informatics, Division of Informatics, Imaging and Data Science, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Victoria Palin
- Centre for Health Informatics, Division of Informatics, Imaging and Data Science, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Christopher J Armitage
- Manchester Centre for Health Psychology, Faculty of Biology, Medicine and Health, Division of Psychology and Mental Health, School of Health Sciences, The University of Manchester, Manchester, UK
- Academic Health Science Centre, Manchester University NHS Foundation Trust (MFT), NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester, Manchester, UK
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17
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Affiliation(s)
- Michael Moore
- Primary Care Research Centre, Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton
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18
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Shajiei A, Berends MS, Luz CF, van Oers JA, Harmsen HJM, Vos P, Klont R, Loef BG, Reidinga AC, Bormans-Russell L, Linsen K, Dormans T, Otten M, van der Bij A, Beishuizen A, de Lange DW, de Jong E, Nijsten MW. Impact of reduced antibiotic treatment duration on antimicrobial resistance in critically ill patients in the randomized controlled SAPS-trial. Front Med (Lausanne) 2023; 10:1080007. [PMID: 36817782 PMCID: PMC9932263 DOI: 10.3389/fmed.2023.1080007] [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: 10/25/2022] [Accepted: 01/09/2023] [Indexed: 02/05/2023] Open
Abstract
Background In the previously reported SAPS trial (https://clinicaltrials.gov/ct2/show/NCT01139489), procalcitonin-guidance safely reduced the duration of antibiotic treatment in critically ill patients. We assessed the impact of shorter antibiotic treatment on antimicrobial resistance development in SAPS patients. Materials and methods Cultures were assessed for the presence of multi-drug resistant (MDR) or highly resistant organisms (HRMO) and compared between PCT-guided and control patients. Baseline isolates from 30 days before to 5 days after randomization were compared with those from 5 to 30 days post-randomization. The primary endpoint was the incidence of new MDR/HRMO positive patients. Results In total, 8,113 cultures with 96,515 antibiotic test results were evaluated for 439 and 482 patients randomized to the PCT and control groups, respectively. Disease severity at admission was similar for both groups. Median (IQR) durations of the first course of antibiotics were 6 days (4-10) and 7 days (5-11), respectively (p = 0.0001). Antibiotic-free days were 7 days (IQR 0-14) and 6 days (0-13; p = 0.05). Of all isolates assessed, 13% were MDR/HRMO positive and at baseline 186 (20%) patients were MDR/HMRO-positive. The incidence of new MDR/HRMO was 39 (8.9%) and 45 (9.3%) in PCT and control patients, respectively (p = 0.82). The time courses for MDR/HRMO development were also similar for both groups (p = 0.33). Conclusions In the 921 randomized patients studied, the small but statistically significant reduction in antibiotic treatment in the PCT-group did not translate into a detectable change in antimicrobial resistance. Studies with larger differences in antibiotic treatment duration, larger study populations or populations with higher MDR/HRMO incidences might detect such differences.
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Affiliation(s)
- Arezoo Shajiei
- Department of Critical Care, University Medical Center Groningen, Groningen, Netherlands,Department of Medical Microbiology, University Medical Center Groningen, Groningen, Netherlands
| | - Matthijs S. Berends
- Department of Medical Microbiology, University Medical Center Groningen, Groningen, Netherlands,Department of Medical Epidemiology, Certe Foundation, Groningen, Netherlands
| | - Christian F. Luz
- Department of Medical Microbiology, University Medical Center Groningen, Groningen, Netherlands
| | - Jos A. van Oers
- Department of Intensive Care, Elisabeth-Tweesteden Ziekenhuis, Tilburg, Netherlands
| | - Hermie J. M. Harmsen
- Department of Medical Microbiology, University Medical Center Groningen, Groningen, Netherlands
| | - Piet Vos
- Department of Intensive Care, Elisabeth-Tweesteden Ziekenhuis, Tilburg, Netherlands
| | - Rob Klont
- Laboratorium Microbiologie Twente Achterhoek, Hengelo, Netherlands
| | - Bert G. Loef
- Department of Intensive Care, Martini Hospital Groningen, Groningen, Netherlands
| | - Auke C. Reidinga
- Department of Intensive Care, Martini Hospital Groningen, Groningen, Netherlands
| | | | - Kitty Linsen
- Department of Intensive Care, Zuyderland Medical Center, Heerlen, Netherlands
| | - Tom Dormans
- Department of Intensive Care, Zuyderland Medical Center, Heerlen, Netherlands
| | - Martine Otten
- Department of Intensive Care, Diakonessenhuis Utrecht, Utrecht, Netherlands
| | - Akke van der Bij
- Department of Microbiology and Immunology, Diakonessenhuis Utrecht, Utrecht, Netherlands
| | | | - Dylan W. de Lange
- Department of Intensive Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Evelien de Jong
- Department of Intensive Care, Beverwijk Hospital, Beverwijk, Netherlands,Department of Intensive Care, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Maarten W. Nijsten
- Department of Critical Care, University Medical Center Groningen, Groningen, Netherlands,*Correspondence: Maarten W. Nijsten ✉
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19
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Raban MZ, Gonzalez G, Nguyen AD, Newell BR, Li L, Seaman KL, Westbrook JI. Nudge interventions to reduce unnecessary antibiotic prescribing in primary care: a systematic review. BMJ Open 2023; 13:e062688. [PMID: 36657758 PMCID: PMC9853249 DOI: 10.1136/bmjopen-2022-062688] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVES Antibiotic prescribing in primary care contributes significantly to antibiotic overuse. Nudge interventions alter the decision-making environment to achieve behaviour change without restricting options. Our objectives were to conduct a systematic review to describe the types of nudge interventions used to reduce unnecessary antibiotic prescribing in primary care, their key features, and their effects on antibiotic prescribing overall. METHODS Medline, Embase and grey literature were searched for randomised trials or regression discontinuity studies in April 2021. Risk of bias was assessed independently by two researchers using the Cochrane Effective Practice and Organisation of Care group's tool. Results were synthesised to report the percentage of studies demonstrating a reduction in overall antibiotic prescribing for different types of nudges. Effects of social norm nudges were examined for features that may enhance effectiveness. RESULTS Nineteen studies were included, testing 23 nudge interventions. Four studies were rated as having a high risk of bias, nine as moderate risk of bias and six as at low risk. Overall, 78.3% (n=18, 95% CI 58.1 to 90.3) of the nudges evaluated resulted in a reduction in overall antibiotic prescribing. Social norm feedback was the most frequently applied nudge (n=17), with 76.5% (n=13; 95% CI 52.7 to 90.4) of these studies reporting a reduction. Other nudges applied were changing option consequences (n=3; with 2 reporting a reduction), providing reminders (n=2; 2 reporting a reduction) and facilitating commitment (n=1; reporting a reduction). Successful social norm nudges typically either included an injunctive norm, compared prescribing to physicians with the lowest prescribers or targeted high prescribers. CONCLUSIONS Nudge interventions are effective for improving antibiotic prescribing in primary care. Expanding the use of nudge interventions beyond social norm nudges could reap further improvements in antibiotic prescribing practices. Policy-makers and managers need to be mindful of how social norm nudges are implemented to enhance intervention effects.
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Affiliation(s)
- Magdalena Z Raban
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Gabriela Gonzalez
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Amy D Nguyen
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
- St Vincent's Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Ben R Newell
- School of Psychology, University of New South Wales, Sydney, New South Wales, Australia
| | - Ling Li
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Karla L Seaman
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Johanna I Westbrook
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
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20
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Tran HH, Nguyen HAT, Tran HB, Vu BNT, Nguyen TCT, Tacoli C, Tran TP, Trinh TS, Cai THN, Nadjm B, Tran KHT, Pham QD, Nguyen THT, Nguyen TT, Pham TD, Kesteman T, Dang DA, Tran TD, van Doorn HR, Lewycka S. Feasibility, acceptability, and bacterial recovery for community-based sample collection to estimate antibiotic resistance in commensal gut and upper respiratory tract bacteria. Sci Rep 2022; 12:22512. [PMID: 36581706 PMCID: PMC9797900 DOI: 10.1038/s41598-022-27084-z] [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: 06/07/2022] [Accepted: 12/26/2022] [Indexed: 12/30/2022] Open
Abstract
Vietnam has high rates of antibiotic use and resistance. Measuring resistance in commensal bacteria could provide an objective indicator for evaluating the impact of interventions to reduce antibiotic use and resistance. This study aimed to evaluate the feasibility, acceptability, and bacterial recovery for different sampling strategies. We conducted a cross-sectional mixed methods study in a rural community in Ha Nam Province, northern Vietnam, and collected structured interviews, samples, and in-depth interviews from households. Out of 389 households invited, 324 participated (83%), representing 1502 individuals. Samples were collected from these individuals (1498 stool, 1002 self-administered nasal swabs, and 496 HW-administered nasopharyngeal swabs). Pneumococci were recovered from 11.1% (128/1149) of the total population and 26.2% (48/183) of those under 5-years. Recovery was higher for health-worker (HW)-administered swabs (13.7%, 48/350) than self-administered swabs (10.0%, 80/799) (OR 2.06, 95% CI 1.07-3.96). Cost per swab was cheaper for self-administered ($7.26) than HW-administered ($8.63) swabs, but the overall cost for 100 positive samples was higher ($7260 and $6300 respectively). Qualitative interviews revealed that HW-administered nasopharyngeal swabs took longer to collect, caused more discomfort, and were more difficult to take from children. Factors affecting participation included sense of contribution, perceived trade-offs between benefits and effort, and peer influence. Reluctance was related to stool sampling and negative perceptions of research. This study provides important evidence for planning community-based carriage studies, including cost, logistics, and acceptability. Self-administered swabs had lower recovery, and though cheaper and quicker, this would translate to higher costs for large population-based studies. Recovery might be improved by swab-type, transport medium, and better cold-chain to lab.
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Affiliation(s)
- Hoang Huy Tran
- National Institute for Hygiene and Epidemiology, Hanoi, Vietnam
| | | | | | | | | | | | | | - Tung Son Trinh
- Oxford University Clinical Research Unit, Hanoi, Vietnam
| | | | - Behzad Nadjm
- Oxford University Clinical Research Unit, Hanoi, Vietnam.,Medical Research Council Unit The Gambia at the London, School of Hygiene and Tropical Medicine, Serekunda, The Gambia
| | | | | | | | | | - Thai Duy Pham
- National Institute for Hygiene and Epidemiology, Hanoi, Vietnam
| | - Thomas Kesteman
- Oxford University Clinical Research Unit, Hanoi, Vietnam.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Duc Anh Dang
- National Institute for Hygiene and Epidemiology, Hanoi, Vietnam
| | - Tien Dac Tran
- Centre for Disease Control, Phu Ly, Ha Nam Province, Vietnam
| | - H Rogier van Doorn
- Oxford University Clinical Research Unit, Hanoi, Vietnam.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Sonia Lewycka
- Oxford University Clinical Research Unit, Hanoi, Vietnam. .,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
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21
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Boaitey KP, Bakhit M, Krzyzaniak N, Hoffmann TC. Information about the natural history of acute infections commonly seen in primary care: a systematic review of clinical practice guidelines. BMC Infect Dis 2022; 22:897. [PMID: 36456959 PMCID: PMC9714117 DOI: 10.1186/s12879-022-07887-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 11/21/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Many of the acute infections that are seen in primary care and sometimes managed with antibiotics are self-resolving and antibiotics may be unnecessary. Information about the natural history of these infections underpins antibiotic stewardship strategies such as delayed prescribing and shared decision making, yet whether it's reported in guidelines is unknown. We examined, in clinical guidelines, the reporting of natural history information and relevant antibiotic stewardship strategies for acute infections commonly seen in primary care. METHODS A systematic review of national and international guidelines (2010 onwards), available electronically, for managing acute infections (respiratory, urinary, or skin and soft tissue). We searched MEDLINE, CINAHL, EMBASE, TRIP, and GIN databases and websites of 22 guideline-publishing organisations. RESULTS We identified 82 guidelines, covering 114 eligible infections. Natural history information was reported in 49 (59.8%) of the guidelines and 66 (57.9%) of the reported conditions, most commonly for respiratory tract infections. Quantitative information about the expected infection duration was provided for 63.5% (n = 42) of the infections. Delayed antibiotic prescribing strategy was recommended for 34.2% (n = 39) of them and shared decision making for 21% (n = 24). CONCLUSIONS Just over half of the guidelines for acute infections that are commonly managed in primary care and sometimes with antibiotics contained natural history information. As many of these infections spontaneously improve, this is a missed opportunity to disseminate this information to clinicians, promote antibiotic stewardship, and facilitate conversations with patients and informed decision making. Systematic review registration CRD42021247048.
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Affiliation(s)
- Kwame Peprah Boaitey
- Faculty of Health Sciences and Medicine, Institute for Evidence-Based Healthcare, Bond University, 14 University Dr, Robina, QLD, 4229, Australia.
| | - Mina Bakhit
- Faculty of Health Sciences and Medicine, Institute for Evidence-Based Healthcare, Bond University, 14 University Dr, Robina, QLD, 4229, Australia
| | - Natalia Krzyzaniak
- Faculty of Health Sciences and Medicine, Institute for Evidence-Based Healthcare, Bond University, 14 University Dr, Robina, QLD, 4229, Australia
| | - Tammy C Hoffmann
- Faculty of Health Sciences and Medicine, Institute for Evidence-Based Healthcare, Bond University, 14 University Dr, Robina, QLD, 4229, Australia
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22
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Bursey K, Hall A, Pike A, Etchegary H, Aubrey-Bassler K, Patey AM, Romme K. Physician-reported barriers to using evidence-based antibiotic prescription guidelines in primary care: protocol for a systematic review and synthesis of qualitative studies using the Theoretical Domains Framework. BMJ Open 2022; 12:e066681. [PMID: 36319054 PMCID: PMC9628688 DOI: 10.1136/bmjopen-2022-066681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Overprescription of antibiotics poses a significant threat to healthcare globally as it contributes to the issue of antibiotic resistance. While antibiotics should be predominately prescribed for bacterial infections, they are often inappropriately given for uncomplicated upper respiratory tract infections (URTIs) and related conditions, such as the common cold. This study will involve a qualitative systematic review of physician-reported barriers to using evidence-based antibiotic prescription guidelines in primary care settings and synthesise the findings using a theoretical basis. METHODS AND ANALYSIS We will conduct a systematic review of qualitative studies that assess physicians' reported barriers to following evidence-based antibiotic prescription guidelines in primary care settings for URTIs. We plan to search the following databases with no date or language restrictions: MEDLINE, Web of Science, CINAHL, Embase, the Cochrane Library and PsycInfo. Qualitative studies that explore the barriers and enablers to following antibiotic prescription guidelines for URTIs for primary care physicians will be included. We will analyse our findings using the Theoretical Domains Framework (TDF), which is a theoretically designed resource based on numerous behaviour change theories grouped into 14 domains. Using the TDF approach, we will be able to identify the determinants of our behaviour of interest (ie, following antibiotic prescription guidelines for URTIs) and categorise them into the 14 TDF domains. This will provide the necessary information to develop future evidence-based interventions that will target the identified issues and apply the most effective behaviour change techniques to affect change. This protocol follows the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols guidelines. ETHICS AND DISSEMINATION Ethical approval is not required. Findings will be published in a peer-reviewed journal and presented at conferences.
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Affiliation(s)
- Krystal Bursey
- Primary Healthcare Research Unit, Memorial University of Newfoundland, St John's, Newfoundland and Labrador, Canada
| | - Amanda Hall
- Primary Healthcare Research Unit, Memorial University of Newfoundland, St John's, Newfoundland and Labrador, Canada
| | - Andrea Pike
- Primary Healthcare Research Unit, Memorial University of Newfoundland, St John's, Newfoundland and Labrador, Canada
| | - Holly Etchegary
- Clinical Epidemiology, Memorial University of Newfoundland, St John's, Newfoundland and Labrador, Canada
| | - Kris Aubrey-Bassler
- Primary Healthcare Research Unit, Memorial University of Newfoundland, St John's, Newfoundland and Labrador, Canada
| | - Andrea M Patey
- Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Kristen Romme
- Medicine, Memorial University of Newfoundland, St John's, Newfoundland and Labrador, Canada
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23
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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: 18] [Impact Index Per Article: 9.0] [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.
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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
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24
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Improving primary care antimicrobial stewardship by implementing a peer audit and feedback intervention in Cape Town community healthcare centres. S Afr Med J 2022; 112:812-818. [PMID: 36472332 DOI: 10.7196/samj.2022.v112i10.16397] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND The increasing prevalence of antibiotic resistance is a major threat to public health. Primary care, where 80% of antibiotics are consumed, is a pivotal setting to direct antimicrobial stewardship (AMS) efforts. However, the ideal model to improve antibiotic prescribing in primary care in low-resource settings is not known. OBJECTIVE To implement a multidisciplinary audit and feedback AMS intervention with the aim to improve appropriate antibiotic prescribing at primary care level. METHODS The intervention was implemented and monitored in 10 primary care centres of the Cape Town metropole between July 2017 and June 2019. The primary and secondary outcome measures were monthly adherence to a bundle of antibiotic quality process measures and monthly antibiotic consumption, respectively. Multidisciplinary audit and feedback meetings were initiated and integrated into facility clinical meetings. Two Excel tools were utilised to automatically calculate facility audit scores and consumption. Once a month, 10 antibiotic prescriptions were randomly selected for a peer review audit by the team. The prescriptions were audited for adherence to a bundle of seven antibiotic process measures using the standard treatment guidelines (STG) and Essential Medicines List (EML) as standard. Concurrently, primary care pharmacists monitored monthly antibiotic consumption by calculating defined daily doses (DDDs) per 100 prescriptions dispensed. Adherence and consumption feedback were regularly provided to the facilities. Learning collaboratives involving representative multidisciplinary teams were held twice-yearly. Pre-, baseline and post-intervention periods were defined as 6 months before, first 6 months and last 6 months of the study, respectively. RESULTS The mean overall adherence increased from 19% (baseline) to 47% (post intervention) (p<0.001). Of the 2 077 prescriptions analysed, 33.7% had an antibiotic prescribed inappropriately. No diagnosis had been captured in patient notes, and the antibiotic chosen was not according to the STG and EML in 30.1% and 31.7% of cases, respectively. Seasonal variation was observed in prescribing adherence, with significantly lower adherence in winter and spring months (adjusted odds ratio 0.60). A reduction of 12.9 DDDs between the pre- and post-intervention periods (p=0.0084) was documented, which represented a 19.3% decrease in antibiotic consumption. CONCLUSION The study demonstrated that peer reviewed audit and feedback is an effective AMS intervention to improve antibiotic prescribing in primary care in a low-resource setting. The intervention, utilising existing resources and involving multidisciplinary engagement, may be incorporated into existing quality improvement processes at facility level, to ensure sustainable change.
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25
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Guo H, Hildon ZJL, Chow A. "Antibiotics are for everyone, our past and our future generations, right? If antibiotics are dead, we will be in big trouble": Building on community values for public engagement on appropriate use of antibiotics in Singapore. Front Public Health 2022; 10:1001282. [PMID: 36249259 PMCID: PMC9561345 DOI: 10.3389/fpubh.2022.1001282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 09/14/2022] [Indexed: 01/26/2023] Open
Abstract
Introduction Shared decision-making (SDM) and trust building through continuity of care are known to play a pivotal role in improving appropriate antibiotic prescribing and use. Problem However, less is known about how to effectively leverage these factors when present-or overcome them when not-to address community needs and improve patient liaison. Methods We addressed this question using a convergent parallel mixed-methods design. Focus group discussions (N = 13; August 2018-September 2020), were analyzed alongside a nationally-representative cross-sectional survey (N = 2004; November 2020-January 2021), in Singapore. Descriptive quantitative analyses and multivariable logistic regression were undertaken to examine antibiotic knowledge and factors associated with preference for SDM. Qualitative applied thematic analysis was integrated with these data to further explain the findings. Findings Poor knowledge and misbeliefs on appropriate antibiotic use and antimicrobial resistance (AMR) were identified. For example, only 9% of the surveyed population understood that AMR occurs when the bacteria, not the human body, become resistant to antibiotics. Qualitative data corroborated the survey findings and suggested a shared value was placed on public education to avoid the fallout from resistant bacterial strains on current and future generations. This study also identified the opportunity to harness community trust in primary care doctors, who were described as highly valued educators for antibiotic use and AMR. Those who had trust in doctors were 75% more likely to prefer SDM (aOR 1.75, 95% CI 1.10-2.77, P = 0.017), especially adults aged ≥50 years who were receiving continued care with a regular doctor (aOR 1.83, 95% CI 1.18-2.86, P = 0.007). Continuity of care was observed to value-add SDM by building trusting relationships, though it was often absent in younger populations. Conclusion This study highlights the long-term value-add of building on cultural capital pertaining to appropriate antibiotic use and AMR, by leveraging on the role of trust in doctors, desire for SDM and anchoring these in continuity of care when possible. Recommendations Using focused messaging and exploring alternative channels of communications such as annual check-ins or tele-consultations with a regular doctor, and emphasizing continuity of care across all age groups would help bridge the identified gaps.
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Affiliation(s)
- Huiling Guo
- 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 and National University Health System, National University of Singapore, Singapore, Singapore
| | - Zoe Jane-Lara Hildon
- Saw Swee Hock School of Public Health and National University Health System, National University of Singapore, Singapore, Singapore
- National Centre for Infectious Diseases, Ministry of Health, 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 and National University Health System, National University of Singapore, Singapore, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
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Kühn L, Kronsteiner D, Kaufmann-Kolle P, Andres E, Szecsenyi J, Wensing M, Poss-Doering R. Implementation fidelity in a multifaceted program to foster rational antibiotics use in primary care: an observational study. BMC Med Res Methodol 2022; 22:243. [PMID: 36123597 PMCID: PMC9487096 DOI: 10.1186/s12874-022-01725-3] [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: 06/09/2021] [Accepted: 09/08/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The ARena study (Sustainable Reduction of Antimicrobial Resistance in German Ambulatory Care) is a three-arm, cluster randomized trial to evaluate a multifaceted implementation program in a German primary care setting. In the context of a prospective process evaluation conducted alongside ARena, this study aimed to document and explore fidelity of the implementation program. METHODS This observational study is based on data generated in a three-wave survey of 312 participating physicians in the ARena program and attendance documentation. Measures concerned persistence of participation in the ARena program and adherence to intervention components (thematic quality circles, e-learning, basic expenditure reimbursements, additional bonus payments and a computerized decision support system). Participants' views on five domains of the implementation were also measured. Binary logistic and multiple linear regression analyses were used to explore which views on the implementation were associated with participants' adherence to quality circles and use of additional bonus compensation. RESULTS The analysis of fidelity showed overall high persistence of participation in the intervention components across the three intervention arms (90,1%; 97,9%; 92,9%). 96.4% of planned quality circles were delivered to study participants and, across waves, 30.4% to 93% of practices participated; 56.1% of physicians attended the maximum of four quality circles. 84% of the practices (n = 158) with a minimum of one index patient received a performance-based additional bonus payment at least once. In total, bonus compensation was triggered for 51.8% of affected patients. Participation rate for e-learning (a prerequisite for reimbursement of project-related expenditure) covered 90.8% of practices across all intervention arms, with the highest rate in arm II (96.5%). Uptake of expenditure reimbursement was heterogeneous across study arms, with a mean rate of 86.5% (89.1% in arm I, 96.4% in arm II and 74.1% in arm III). Participants' views regarding participant responsiveness (OR = 2.298) 95% CI [1.598, 3.305] and Context (OR = 2.146) 95% CI [1.135, 4.055] affected additional bonus payment. Participants' views on participant responsiveness (Beta = 0.718) 95% CI [0.479, 0.957], Context (Beta = 0.323) 95% CI [0.055, 0.590] and Culture of shared decision-making (Beta = -0.334) 95% CI [-0.614, -0.053] affected quality circle attendance. CONCLUSION This study showed an overall high fidelity to the implementation program. Participants' views on the implementation were associated with degree of intervention fidelity. TRIAL REGISTRATION ISRCTN, ISRCTN58150046.
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Affiliation(s)
- Lukas Kühn
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - Dorothea Kronsteiner
- Institute of Medical Biometry, University of Heidelberg, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | | | - Edith Andres
- aQua Institut, Maschmuehlenweg 8-10, 37073, Goettingen, Germany
| | - Joachim Szecsenyi
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany.,aQua Institut, Maschmuehlenweg 8-10, 37073, Goettingen, Germany
| | - Michel Wensing
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - Regina Poss-Doering
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany.
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Rocha V, Estrela M, Neto V, Roque F, Figueiras A, Herdeiro MT. Educational Interventions to Reduce Prescription and Dispensing of Antibiotics in Primary Care: A Systematic Review of Economic Impact. Antibiotics (Basel) 2022; 11:1186. [PMID: 36139965 PMCID: PMC9495011 DOI: 10.3390/antibiotics11091186] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [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.
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Affiliation(s)
- Vânia Rocha
- Institute of Biomedicine (iBiMED), Department of Medical Sciences, University of Aveiro, 3810-193 Aveiro, Portugal
| | - Marta Estrela
- Institute of Biomedicine (iBiMED), Department of Medical Sciences, University of Aveiro, 3810-193 Aveiro, Portugal
| | - Vanessa Neto
- Institute of Biomedicine (iBiMED), Department of Medical Sciences, University of Aveiro, 3810-193 Aveiro, Portugal
| | - Fátima Roque
- Research Unit for Inland Development, Polytechnic of Guarda (UDI-IPG), 6300-559 Guarda, Portugal
- Health Sciences Research Centre, University of Beira Interior (CICS-UBI), 6201-001 Covilhã, Portugal
| | - Adolfo Figueiras
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, 15702 Santiago de Compostela, Spain
- Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBER Epidemiology and Public Health—CIBERESP), 28001 Madrid, Spain
| | - Maria Teresa Herdeiro
- Institute of Biomedicine (iBiMED), Department of Medical Sciences, University of Aveiro, 3810-193 Aveiro, Portugal
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28
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Dixon S, Fanshawe TR, Mwandigha L, Edwards G, Turner PJ, Glogowska M, Gillespie MM, Blair D, Hayward GN. The Impact of Point-of-Care Blood C-Reactive Protein Testing on Prescribing Antibiotics in Out-of-Hours Primary Care: A Mixed Methods Evaluation. Antibiotics (Basel) 2022; 11:antibiotics11081008. [PMID: 35892398 PMCID: PMC9332095 DOI: 10.3390/antibiotics11081008] [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: 06/21/2022] [Revised: 07/15/2022] [Accepted: 07/18/2022] [Indexed: 02/05/2023] Open
Abstract
Improving prescribing antibiotics appropriately for respiratory infections in primary care is an antimicrobial stewardship priority. There is limited evidence to support interventions to reduce prescribing antibiotics in out-of-hours (OOH) primary care. Herein, we report a service innovation where point-of-care C-Reactive Protein (CRP) machines were introduced to three out-of-hours primary care clinical bases in England from August 2018-December 2019, which were compared with four control bases that did not have point-of-care CRP testing. We undertook a mixed-method evaluation, including a comparative interrupted time series analysis to compare monthly antibiotic prescription rates between bases with CRP machines and those without, an analysis of the number of and reasons for the tests performed, and qualitative interviews with clinicians. Antibiotic prescription rates declined during follow-up, but with no clear difference between the two groups of out-of-hours practices. A single base contributed 217 of the 248 CRP tests performed. Clinicians reported that the tests supported decision making and communication about not prescribing antibiotics, where having 'objective' numbers were helpful in navigating non-prescribing decisions and highlighted the challenges of training a fluctuant staff group and practical concerns about using the CRP machine. Service improvements to reduce prescribing antibiotics in out-of-hours primary care need to be developed with an understanding of the needs and context of this service.
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Affiliation(s)
- Sharon Dixon
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Woodstock Road, Oxford OX2 6GG, UK; (T.R.F.); (L.M.); (G.E.); (P.J.T.); (M.G.); (G.N.H.)
- Correspondence:
| | - Thomas R. Fanshawe
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Woodstock Road, Oxford OX2 6GG, UK; (T.R.F.); (L.M.); (G.E.); (P.J.T.); (M.G.); (G.N.H.)
| | - Lazaro Mwandigha
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Woodstock Road, Oxford OX2 6GG, UK; (T.R.F.); (L.M.); (G.E.); (P.J.T.); (M.G.); (G.N.H.)
| | - George Edwards
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Woodstock Road, Oxford OX2 6GG, UK; (T.R.F.); (L.M.); (G.E.); (P.J.T.); (M.G.); (G.N.H.)
| | - Philip J. Turner
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Woodstock Road, Oxford OX2 6GG, UK; (T.R.F.); (L.M.); (G.E.); (P.J.T.); (M.G.); (G.N.H.)
| | - Margaret Glogowska
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Woodstock Road, Oxford OX2 6GG, UK; (T.R.F.); (L.M.); (G.E.); (P.J.T.); (M.G.); (G.N.H.)
| | - Marjorie M. Gillespie
- Practice Plus Group, Hawker House, 5–6 Napier Court, Napier Road, Reading, Berkshire RG1 8BW, UK;
| | - Duncan Blair
- Queen Elizabeth Memorial Health Centre, St Michaels Avenue, Tidworth Garrison SP9 7EA, UK;
| | - Gail N. Hayward
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Woodstock Road, Oxford OX2 6GG, UK; (T.R.F.); (L.M.); (G.E.); (P.J.T.); (M.G.); (G.N.H.)
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29
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Eng ME, Imperio GE, Bloise E, Matthews SG. ATP-binding cassette (ABC) drug transporters in the developing blood-brain barrier: role in fetal brain protection. Cell Mol Life Sci 2022; 79:415. [PMID: 35821142 PMCID: PMC11071850 DOI: 10.1007/s00018-022-04432-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 05/27/2022] [Accepted: 06/15/2022] [Indexed: 12/19/2022]
Abstract
The blood-brain barrier (BBB) provides essential neuroprotection from environmental toxins and xenobiotics, through high expression of drug efflux transporters in endothelial cells of the cerebral capillaries. However, xenobiotic exposure, stress, and inflammatory stimuli have the potential to disrupt BBB permeability in fetal and post-natal life. Understanding the role and ability of the BBB in protecting the developing brain, particularly with respect to drug/toxin transport, is key to promoting long-term brain health. Drug transporters, particularly P-gp and BCRP are expressed in early gestation at the developing BBB and have a crucial role in developmental homeostasis and fetal brain protection. We have highlighted several factors that modulate drug transporters at the developing BBB, including synthetic glucocorticoid (sGC), cytokines, maternal infection, and growth factors. Some factors have the potential to increase expression and function of drug transporters and increase brain protection (e.g., sGC, transforming growth factor [TGF]-β). However, others inhibit drug transporters expression and function at the BBB, increasing brain exposure to xenobiotics (e.g., tumor necrosis factor [TNF], interleukin [IL]-6), negatively impacting brain development. This has implications for pregnant women and neonates, who represent a vulnerable population and may be exposed to drugs and environmental toxins, many of which are P-gp and BCRP substrates. Thus, alterations in regulated transport across the developing BBB may induce long-term changes in brain health and compromise pregnancy outcome. Furthermore, a large portion of neonatal adverse drug reactions are attributed to agents that target or access the nervous system, such as stimulants (e.g., caffeine), anesthetics (e.g., midazolam), analgesics (e.g., morphine) and antiretrovirals (e.g., Zidovudine); thus, understanding brain protection is key for the development of strategies to protect the fetal and neonatal brain.
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Affiliation(s)
- Margaret E Eng
- Department of Physiology, Temerty Faculty of Medicine, University of Toronto, Medical Sciences Bldg. Rm. 3207. 1 King's College Circle, Toronto, ON, M5S 1A8, Canada
| | | | - Enrrico Bloise
- Department of Physiology, Temerty Faculty of Medicine, University of Toronto, Medical Sciences Bldg. Rm. 3207. 1 King's College Circle, Toronto, ON, M5S 1A8, Canada
- Lunenfeld-Tanenbaum Research Institute, Sinai Health, Toronto, Canada
- Department of Morphology, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Stephen G Matthews
- Department of Physiology, Temerty Faculty of Medicine, University of Toronto, Medical Sciences Bldg. Rm. 3207. 1 King's College Circle, Toronto, ON, M5S 1A8, Canada.
- Lunenfeld-Tanenbaum Research Institute, Sinai Health, Toronto, Canada.
- Department of Obstetrics and Gynecology, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada.
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada.
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30
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Watkins RR. Using Precision Medicine for the Diagnosis and Treatment of Viral Pneumonia. Adv Ther 2022; 39:3061-3071. [PMID: 35596912 PMCID: PMC9123616 DOI: 10.1007/s12325-022-02180-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 05/04/2022] [Indexed: 01/06/2023]
Abstract
The COVID-19 pandemic has drawn considerable attention to viral pneumonia from clinicians, public health authorities, and the general public. With dozens of viruses able to cause pneumonia in humans, differentiating viral from bacterial pneumonia can be very challenging in clinical practice using traditional diagnostic methods. Precision medicine is a medical model in which decisions, practices, interventions, and therapies are adapted to the individual patient on the basis of their predicted response or risk of disease. Precision medicine approaches hold promise as a way to improve outcomes for patients with viral pneumonia. This review describes the latest advances in the use of precision medicine for diagnosing and treating viral pneumonia in adults and discusses areas where further research is warranted.
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Affiliation(s)
- Richard R Watkins
- Department of Medicine, Northeast Ohio Medical University, Rootstown, OH, USA.
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31
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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; 11:543. [PMID: 35625187 PMCID: PMC9137646 DOI: 10.3390/antibiotics11050543] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [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.
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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
| | - 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.)
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32
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Sydenham RV, Hansen MP, Justesen US, Pedersen LB, Aabenhus RM, Wehberg S, Jarbøl DE. Factors associated with C-reactive protein testing when prescribing antibiotics in general practice: a register-based study. BMC PRIMARY CARE 2022; 23:17. [PMID: 35172735 PMCID: PMC8783519 DOI: 10.1186/s12875-021-01614-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 12/14/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND The use of C-reactive protein (CRP) tests has been shown to safely reduce antibiotic prescribing for acute respiratory tract infections (RTIs). The aim of this study was to explore patient and clinical factors associated with the use of CRP testing when prescribing antibiotics recommended for RTIs. METHODS A nation-wide retrospective cross-sectional register-based study based on first redeemed antibiotic prescriptions issued to adults in Danish general practice between July 2015 and June 2017. Only antibiotics recommended for treatment of RTIs were included in the analysis (penicillin-V, amoxicillin, co-amoxicillin or roxithromycin/clarithromycin). Logistic regression models were used to estimate odds ratios for patient-related and clinical factors on performing a CRP test in relation to antibiotic prescribing. RESULTS A total of 984,149 patients redeemed at least one antibiotic prescription during the two-year period. About half of these prescriptions (49.6%) had an RTI stated as the indication, and a CRP test was performed in relation to 45.2% of these scripts. Lower odds of having a CRP test performed in relation to an antibiotic prescription was found for patients aged 75 years and above (OR 0.82, 95CI 0.79-0.86), with a Charlson Comorbidity Index of more than one (OR 0.93, 95CI 0.91-0.95), unemployed or on disability pension (OR 0.84, 95CI 0.83-0.85) and immigrants (OR 0.91, 95CI 0.88-0.95) or descendants of immigrants (OR 0.90, 95CI 0.84-0.96). Living with a partner (OR 1.08, 95CI 1.07-1.10), being followed in practice for a chronic condition (OR 1.22, 95CI 1.18-1.26) and having CRP tests performed in the previous year (OR 1.78, 95CI 1.73-1.84) were associated with higher odds of CRP testing in relation to antibiotic prescribing. CONCLUSIONS Differences were observed in the use of CRP tests among subgroups of patients indicating that both sociodemographic factors and comorbidity influence the decision to use a CRP test in relation to antibiotic prescriptions in general practice. Potentially, this means that the use of CRP tests could be optimised to increase diagnostic certainty and further promote rational prescribing of antibiotics. The rationale behind the observed differences could be further explored in future qualitative studies.
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Affiliation(s)
- Rikke Vognbjerg Sydenham
- Research Unit of General Practice, Institute of Public Health, University of Southern Denmark, JB Winsløws Vej 9A, 5000, Odense C, Denmark.
| | | | - Ulrik Stenz Justesen
- Department of Clinical Microbiology, Odense University Hospital, Odense, Denmark
| | - Line Bjørnskov Pedersen
- Research Unit of General Practice, Institute of Public Health, University of Southern Denmark, JB Winsløws Vej 9A, 5000, Odense C, Denmark
- Danish Centre for Health Economics, Institute of Public Health, University of Southern Denmark, Odense, Denmark
| | - Rune Munck Aabenhus
- Research Unit for General Practice, University of Copenhagen, Copenhagen, Denmark
| | - Sonja Wehberg
- Research Unit of General Practice, Institute of Public Health, University of Southern Denmark, JB Winsløws Vej 9A, 5000, Odense C, Denmark
| | - Dorte Ejg Jarbøl
- Research Unit of General Practice, Institute of Public Health, University of Southern Denmark, JB Winsløws Vej 9A, 5000, Odense C, Denmark
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Ciccone EJ, Kabugho L, Baguma E, Muhindo R, Juliano JJ, Mulogo E, Boyce RM. Rapid Diagnostic Tests to Guide Case Management of and Improve Antibiotic Stewardship for Pediatric Acute Respiratory Illnesses in Resource-Constrained Settings: a Prospective Cohort Study in Southwestern Uganda. Microbiol Spectr 2021; 9:e0169421. [PMID: 34817224 PMCID: PMC8612158 DOI: 10.1128/spectrum.01694-21] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 10/19/2021] [Indexed: 12/26/2022] Open
Abstract
Pediatric acute respiratory illness (ARI) is one of the most common reasons for evaluation at peripheral health centers in sub-Saharan Africa and is frequently managed based on clinical syndrome alone. Although most ARI episodes are likely caused by self-limited viral infections, the majority are treated with antibiotics. This overuse contributes to the development of antimicrobial resistance. To evaluate the preliminary feasibility and potential impact of adding pathogen-specific and clinical biomarker diagnostic testing to existing clinical management algorithms, we conducted a prospective, observational cohort study of 225 children presenting with malaria-negative, febrile ARI to the outpatient department of a semi-urban peripheral health facility in southwestern Uganda from October 2019 to January 2020. In addition to routine clinical evaluation, we performed influenza and Streptococcus pneumoniae antigen testing and measured levels of C-reactive protein, procalcitonin, and lactate in the clinic's laboratory, and conducted a follow-up assessment by phone 7 days later. Almost one-fifth of participants (40/225) tested positive for influenza. Clinical biomarker measurements were low with C-reactive protein of >40 mg/L in only 11% (13/222) of participants and procalcitonin >0.25 ng/mL in only 13% (16/125). All but two children received antibiotic treatment; only 3% (7/225) were admitted. At follow-up, 59% (118/201) of caregivers reported at least one persistent symptom, but fever had resolved for all children. Positive influenza testing was associated with persistent symptoms. In summary, we demonstrate that simple, rapid pathogen-specific testing and biomarker measurement are possible in resource-limited settings and could improve syndromic management and, in turn, antibiotic stewardship. IMPORTANCE Globally, respiratory illness is one of the most common reasons that children seek care. It is often treated inappropriately with antibiotics, which can drive the development of antibiotic resistance. In resource-rich settings, testing for specific pathogens or measurement of clinical biomarkers, such as procalcitonin and C-reactive protein, is often employed to help determine which children should receive antibiotics. However, there are limited data on the use of these tests in resource-constrained, outpatient contexts in sub-Saharan Africa. We enrolled children with respiratory illness presenting to a clinic in southwestern Uganda and performed testing for influenza, Streptococcus pneumoniae, C-reactive protein, and procalcitonin on-site. Almost all children received antibiotics. We demonstrate that employing clinical algorithms that include influenza and clinical biomarker testing could significantly decrease antibiotic prescriptions. Our study therefore provides preliminary data to support the feasibility and potential utility of diagnostics to improve management of respiratory illness in resource-constrained settings.
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Affiliation(s)
- Emily J. Ciccone
- Division of Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Lydia Kabugho
- Department of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Emmanuel Baguma
- Department of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Rabbison Muhindo
- Department of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Jonathan J. Juliano
- Division of Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Edgar Mulogo
- Department of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Ross M. Boyce
- Division of Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
- Department of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda
- Department of Epidemiology, Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
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Point of care testing, antibiotic prescribing and prescribing confidence for respiratory tract infections in primary care: Prospective audit in 18 European countries. BJGP Open 2021; 6:BJGPO.2021.0212. [PMID: 34920989 PMCID: PMC9447323 DOI: 10.3399/bjgpo.2021.0212] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 12/03/2021] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Between-country differences have been described in antibiotic prescribing for RTI in primary care, but not yet for diagnostic testing procedures and prescribing confidence. AIM To describe between-country differences in RTI management, particularly diagnostic testing and antibiotic prescribing, and investigate which factors relate to antibiotic prescribing and GPs' prescribing confidence. DESIGN & SETTING Prospective audit in 18 European countries. METHOD GPs registered patient-, clinical- and management characteristics, and confidence in their antibiotic prescribing decision for patients presenting with sore throat and/or lower RTI (n=4,982). Factors related to antibiotic prescribing and confidence were analysed using multi-level logistic regression. RESULTS Antibiotic prescribing proportions varied considerably:<20% in four countries, and >40% in six countries. There was also considerable variation in POC testing (0% in Croatia, Moldova, Romania, and >65% in Denmark, Norway, mainly CRP and Strep A), and in lab/hospital-based testing (<3% in Hungary, Netherlands, Spain, and >30% in Croatia, Georgia, Greece, Moldova, mainly chest X-ray and white blood cell counting). Antibiotic prescribing was related to illness severity, comorbidity, age, fever and 'country', but not to having performed a POC test. In nearly 90% of consultations, GPs were confident in their antibiotic prescribing decision. CONCLUSION Despite high confidence in decisions about antibiotic prescribing, there is considerable variation in the primary care of RTI in European countries, with GPs prescribing antibiotics overall more often than is considered appropriate. POC testing may enhance the quality of antibiotic prescribing decisions if it can safely reverse decisions confidently made on clinical grounds alone to prescribe antibiotics.
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Epps A, Albury C, Van Hecke O. Exploring Primary Care Clinicians' Views about How Best to Implement a Potential Trial around Point-of-Care Tests for Common Infections in South Africa. Diagnostics (Basel) 2021; 11:diagnostics11112100. [PMID: 34829447 PMCID: PMC8620116 DOI: 10.3390/diagnostics11112100] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 11/03/2021] [Accepted: 11/11/2021] [Indexed: 11/18/2022] Open
Abstract
Optimisation of antibiotic prescribing is critical to combat antimicrobial resistance. Point-of-care tests (POCTs) for common infections could be a valuable tool to achieve this in primary care. Currently, their use has primarily been studied in high-income countries. Trials in low-and-middle-income countries face challenges unique to their setting. This study aims to explore the barriers and facilitators for a future trial of POCTs for common infections in South Africa. Twenty-three primary care clinicians in the Western Cape Metropole were interviewed. Interview transcripts were analysed using thematic analysis. We identified three key themes. These themes focused on clinicians’ views about proposed trial design and novel POCTs, clinicians’ perspectives about trial set-up, and specific trial procedures. Participants were overall positive about the proposed trial and POCTs. Potential issues centred around the limited space and technology available and participant retention to follow-up. Additionally, impact on clinic workload was an important consideration. These insights will be invaluable in informing the design of a feasibility trial of POCTs in this setting.
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Assessing Reduction of Antibiotic Prescribing for Acute, Non-Complicated Infections in Primary Care in Germany: Multi-Step Outcome Evaluation in the Cluster-Randomized Trial ARena. Antibiotics (Basel) 2021; 10:antibiotics10101151. [PMID: 34680732 PMCID: PMC8532997 DOI: 10.3390/antibiotics10101151] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 09/22/2021] [Accepted: 09/23/2021] [Indexed: 01/22/2023] Open
Abstract
The three-armed cluster-randomized trial ARena (sustainable reduction of antibiotic-induced antimicrobial resistance) aimed to foster appropriate antibiotic use and reduce overprescribing in German ambulatory care to counter antibiotic resistance. Multi-faceted interventions targeted primary care physicians, teams and patients. This study examined the effectiveness of the implementation program. ARena was conducted in 14 primary care networks with 196 practices. All arms received data-based feedback on antibiotics prescribing and quality circles. Arms II and III received different add-on components each. Primary outcome examined is the prescribing rate for systemic antibiotics for cases with non-complicated acute infections (upper respiratory tract, bronchitis, sinusitis, tonsillitis, otitis media). Secondary outcomes refer to the prescribing of quinolones and guideline-recommended antibiotics. Based on pseudonymized quarterly claims data, mixed logistic regression models examined pre-post intervention antibiotic prescribing rate changes and compared to matched standard care. A significant rate reduction (arm I 11.7%; arm II 9.9%; arm III 12.7%) and significantly lower prescribing rates were observed for all arms (20.1%, 18.9% and 23.6%) compared to matched standard care (29.4%). Fluoroquinolone prescribing was reduced in all intervention arms and rates for recommended substances generally increased. No significant post-interventional difference between intervention arms was detected. Findings indicate implementation program impact compared to standard care.
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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.
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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
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Cumulative life stressors and stress response to threatened preterm labour as birth date predictors. Arch Gynecol Obstet 2021; 305:1421-1429. [PMID: 34549310 DOI: 10.1007/s00404-021-06251-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 09/01/2021] [Indexed: 02/05/2023]
Abstract
PURPOSE Preterm birth represents one of the main causes of neonatal morbimortality and a risk factor for neurodevelopmental disorders. Appropriate predictive methods for preterm birth outcome, which consequently would facilitate prevention programs, are needed. We aim to predict birth date in women with a threatened preterm labour (TPL) based on stress response to TPL diagnosis, cumulative life stressors, and relevant obstetric variables. METHODS A prospective cohort of 157 pregnant women with TPL diagnosis between 24 and 31 weeks gestation formed the study sample. To estimate the stress response to TPL, maternal salivary cortisol, α-amylase levels, along with anxiety and depression symptoms were measured. To determine cumulative life stressors, previous traumas, social support, and family functioning were registered. Then, linear regression models were used to examine the effect of potential predictors of birth date. RESULTS Lower family adaptation, higher Body Mass Index (BMI), higher cortisol levels and TPL diagnosis week were the main predictors of birth date. Gestational week at TPL diagnosis showed a non-linear interaction with cortisol levels: TPL women with middle- and high-cortisol levels before 29 weeks of gestation went into imminent labour. CONCLUSION A combination of stress response to TPL diagnosis (salivary cortisol) and cumulative life stressors (family adaptation) together with obstetric factors (TPL gestational week and BMI) was the best birth date predictor. Therefore, a psychosocial therapeutic intervention program aimed to increase family adaptation and decrease cortisol levels at TPL diagnosis as well as losing weight, may prevent preterm birth in symptomatic women.
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Borek AJ, Campbell A, Dent E, Moore M, Butler CC, Holmes A, Walker AS, McLeod M, Tonkin-Crine S. Development of an intervention to support the implementation of evidence-based strategies for optimising antibiotic prescribing in general practice. Implement Sci Commun 2021; 2:104. [PMID: 34526140 PMCID: PMC8441243 DOI: 10.1186/s43058-021-00209-7] [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: 05/24/2021] [Accepted: 08/30/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Trials show that antimicrobial stewardship (AMS) strategies, including communication skills training, point-of-care C-reactive protein testing (POC-CRPT) and delayed prescriptions, help optimise antibiotic prescribing and use in primary care. However, the use of these strategies in general practice is limited and inconsistent. We aimed to develop an intervention to enhance uptake and implementation of these strategies in primary care. METHODS We drew on the Person-Based Approach to develop an implementation intervention in two stages. (1) Planning and design: We defined the problem in behavioural terms drawing on existing literature and conducting primary qualitative research (nine focus groups) in high-prescribing general practices. We identified 'guiding principles' with intervention objectives and key features and developed logic models representing intended mechanisms of action. (2) Developing the intervention: We created prototype intervention materials and discussed and refined these with input from 13 health professionals and 14 citizens in two sets of design workshops. We further refined the intervention materials following think-aloud interviews with 22 health professionals. RESULTS Focus groups highlighted uncertainties about how strategies could be used. Health professionals in the workshops suggested having practice champions, brief summaries of each AMS strategy and evidence supporting the AMS strategies, and they and citizens gave examples of helpful communication strategies/phrases. Think-aloud interviews helped clarify and shorten the text and user journey of the intervention materials. The intervention comprised components to support practice-level implementation: antibiotic champions, practice meetings with slides provided, and an 'implementation support' website section, and components to support individual-level uptake: website sections on each AMS strategy (with evidence, instructions, links to electronic resources) and material resources (patient leaflets, POC-CRPT equipment, clinician handouts). CONCLUSIONS We used a systematic, user-focussed process of developing a behavioural intervention, illustrating how it can be used in an implementation context. This resulted in a multicomponent intervention to facilitate practice-wide implementation of evidence-based strategies which now requires implementing and evaluating. Focusing on supporting the uptake and implementation of evidence-based strategies to optimise antibiotic use in general practice is critical to further support appropriate antibiotic use and mitigate antimicrobial resistance.
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Affiliation(s)
- Aleksandra J Borek
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.
| | - Anne Campbell
- National Institute for Health Research (NIHR) Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
| | - Elle Dent
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Michael Moore
- Primary Care Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, 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
| | - A Sarah Walker
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford, UK
- Nuffield Department of Medicine, 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, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
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Wolfisberg S, Gregoriano C, Schuetz P. Procalcitonin for individualizing antibiotic treatment: an update with a focus on COVID-19. Crit Rev Clin Lab Sci 2021; 59:54-65. [PMID: 34517744 PMCID: PMC8442987 DOI: 10.1080/10408363.2021.1975637] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Procalcitonin (PCT) is useful for differentiating between viral and bacterial infections and for reducing the unnecessary use of antibiotics. As the rise of antimicrobial resistance reaches “alarming” levels according to the World Health Organization, the importance of using biomarkers, such as PCT to limit unnecessary antibiotic exposure has further increased. Randomized trials in patients with respiratory tract infections have shown that PCT has prognostic implications and its use, embedded in stewardship protocols, leads to reductions in the use of antibiotics in different clinical settings without compromising clinical outcomes. However, available data are heterogeneous and recent trials found no significant benefit. Still, from these trials, we have learned several key considerations for the optimal use of PCT, which depend on the clinical setting, severity of presentation, and pretest probability for bacterial infection. For patients with respiratory infections and sepsis, PCT can be used to determine whether to initiate antimicrobial therapy in low-risk settings and, together with clinical data, whether to discontinue antimicrobial therapy in certain high-risk settings. There is also increasing evidence regarding PCT-guided therapy in patients with coronavirus disease 2019 (COVID-19). This review provides an up-to-date overview of the use of PCT in different clinical settings and diseases, including a discussion about its potential to improve the care of patients with COVID-19.
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Affiliation(s)
| | | | - Philipp Schuetz
- Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland.,Medical Faculty, University of Basel, Basel, Switzerland
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Likopa Z, Kivite-Urtane A, Pavare J. Latvian Primary Care Management of Children with Acute Infections: Antibiotic-Prescribing Habits and Diagnostic Process Prior to Treatment. MEDICINA-LITHUANIA 2021; 57:medicina57080831. [PMID: 34441037 PMCID: PMC8397978 DOI: 10.3390/medicina57080831] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 08/11/2021] [Accepted: 08/13/2021] [Indexed: 11/16/2022]
Abstract
Background and Objectives: Primary care physicians frequently prescribe antibiotics for acutely ill children, even though they usually have self-limiting diseases of viral etiology. The aim of this research was to evaluate the routine antibiotic-prescribing habits of primary care in Latvia, in response to children presenting with infections. Materials and Methods: This cross-sectional study included acutely ill children who consulted eighty family physicians (FP) in Latvia, between November 2019 and May 2020. The data regarding patient demographics, diagnoses treated with antibiotics, the choice of antibiotics and the use of diagnostic tests were collected. Results: The study population comprised 2383 patients aged between one month and 17 years, presenting an acute infection episode, who had a face-to-face consultation with an FP. Overall, 29.2% of these patients received an antibiotic prescription. The diagnoses most often treated with antibiotics were otitis (45.8% of all antibiotic prescriptions), acute bronchitis (25.0%) and the common cold (14.8%). The most commonly prescribed antibiotics were amoxicillin (55.9% of prescriptions), amoxicillin/clavulanate (18.1%) and clarithromycin (11.8%). Diagnostic tests were carried out for 59.6% of children presenting with acute infections and preceded 66.4% of antibiotic prescriptions. Conclusion: Our data revealed that a high level of antibiotic prescribing for self-limiting viral infections in children continues to occur. The underuse of narrow-spectrum antibiotics and suboptimal use of diagnostic tests before treatment decision-making were also identified. To achieve a more rational use of antibiotics in primary care for children with a fever, professionals and parents need to be better educated on this subject, and diagnostic tests should be used more extensively, including the implementation of daily point-of-care testing.
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Affiliation(s)
- Zane Likopa
- Children’s Clinical University Hospital, Vienibas Gatve 45, LV-1004 Riga, Latvia;
- Correspondence:
| | - Anda Kivite-Urtane
- Department of Public Health and Epidemiology, Institute of Public Health, Riga Stradins University, Kronvalda Bulvaris 9, LV-1010 Riga, Latvia;
| | - Jana Pavare
- Children’s Clinical University Hospital, Vienibas Gatve 45, LV-1004 Riga, Latvia;
- Department of Pediatrics, Riga Stradins University, Vienibas Gatve 45, LV-1004 Riga, Latvia
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Haak BW, Brands X, Davids M, Peters-Sengers H, Kullberg RFJ, van Houdt R, Hugenholtz F, Faber DR, Zaaijer HL, Scicluna BP, van der Poll T, Wiersinga WJ. Bacterial and viral respiratory tract microbiota and host characteristics in adults with lower respiratory tract infections: a case-control study. Clin Infect Dis 2021; 74:776-784. [PMID: 34156449 PMCID: PMC8906706 DOI: 10.1093/cid/ciab568] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Indexed: 01/04/2023] Open
Abstract
Background Viruses and bacteria from the nasopharynx are capable of causing community-acquired pneumonia (CAP), which can be difficult to diagnose. We aimed to investigate whether shifts in the composition of these nasopharyngeal microbial communities can be used as diagnostic biomarkers for CAP in adults. Methods We collected nasopharyngeal swabs from adult CAP patients and controls without infection in a prospective multicenter case-control study design. We generated bacterial and viral profiles using 16S ribosomal RNA gene sequencing and multiplex polymerase chain reaction (PCR), respectively. Bacterial, viral, and clinical data were subsequently used as inputs for extremely randomized trees classification models aiming to distinguish subjects with CAP from healthy controls. Results We enrolled 117 cases and 48 control subjects. Cases displayed significant beta diversity differences in nasopharyngeal microbiota (P = .016, R2 = .01) compared to healthy controls. Our extremely randomized trees classification models accurately discriminated CAP caused by bacteria (area under the curve [AUC] .83), viruses (AUC .95) or mixed origin (AUC .81) from healthy control subjects. We validated this approach using a dataset of nasopharyngeal samples from 140 influenza patients and 38 controls, which yielded highly accurate (AUC .93) separation between cases and controls. Conclusions Relative proportions of different bacteria and viruses in the nasopharynx can be leveraged to diagnose CAP and identify etiologic agent(s) in adult patients. Such data can inform the development of a microbiota-based diagnostic panel used to identify CAP patients and causative agents from nasopharyngeal samples, potentially improving diagnostic specificity, efficiency, and antimicrobial stewardship practices.
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Affiliation(s)
- Bastiaan W Haak
- Center for Experimental and Molecular Medicine (CEMM), Amsterdam University Medical Centers - Location AMC, University of Amsterdam, Amsterdam, The Netherlands.,Microbiota Center Amsterdam, Amsterdam University Medical Centers - Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Xanthe Brands
- Center for Experimental and Molecular Medicine (CEMM), Amsterdam University Medical Centers - Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Mark Davids
- Microbiota Center Amsterdam, Amsterdam University Medical Centers - Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Hessel Peters-Sengers
- Center for Experimental and Molecular Medicine (CEMM), Amsterdam University Medical Centers - Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Robert F J Kullberg
- Center for Experimental and Molecular Medicine (CEMM), Amsterdam University Medical Centers - Location AMC, University of Amsterdam, Amsterdam, The Netherlands.,Microbiota Center Amsterdam, Amsterdam University Medical Centers - Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Robin van Houdt
- Department of Virology, Amsterdam University Medical Centers - Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Floor Hugenholtz
- Center for Experimental and Molecular Medicine (CEMM), Amsterdam University Medical Centers - Location AMC, University of Amsterdam, Amsterdam, The Netherlands.,Microbiota Center Amsterdam, Amsterdam University Medical Centers - Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Daniël R Faber
- Department of Internal Medicine, BovenIJ hospital, Amsterdam, The Netherlands
| | - Hans L Zaaijer
- Department of Virology, Amsterdam University Medical Centers - Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Brendon P Scicluna
- Center for Experimental and Molecular Medicine (CEMM), Amsterdam University Medical Centers - Location AMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam University Medical Centers - Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Tom van der Poll
- Center for Experimental and Molecular Medicine (CEMM), Amsterdam University Medical Centers - Location AMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Internal Medicine, Division of Infectious Diseases, Amsterdam University Medical Centers - Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - W Joost Wiersinga
- Center for Experimental and Molecular Medicine (CEMM), Amsterdam University Medical Centers - Location AMC, University of Amsterdam, Amsterdam, The Netherlands.,Microbiota Center Amsterdam, Amsterdam University Medical Centers - Location AMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Internal Medicine, Division of Infectious Diseases, Amsterdam University Medical Centers - Location AMC, University of Amsterdam, Amsterdam, The Netherlands
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Gulliford MC, Charlton J, Boiko O, Winter JR, Rezel-Potts E, Sun X, Burgess C, McDermott L, Bunce C, Shearer J, Curcin V, Fox R, Hay AD, Little P, Moore MV, Ashworth M. Safety of reducing antibiotic prescribing in primary care: a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2021. [DOI: 10.3310/hsdr09090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background
The threat of antimicrobial resistance has led to intensified efforts to reduce antibiotic utilisation, but serious bacterial infections are increasing in frequency.
Objectives
To estimate the risks of serious bacterial infections in association with lower antibiotic prescribing and understand stakeholder views with respect to safe antibiotic reduction.
Design
Mixed-methods research was undertaken, including a qualitative interview study of patient and prescriber views that informed a cohort study and a decision-analytic model, using primary care electronic health records. These three work packages were used to design an application (app) for primary care prescribers.
Data sources
The Clinical Practice Research Datalink.
Setting
This took place in UK general practices.
Participants
A total of 706 general practices with 66.2 million person-years of follow-up from 2002 to 2017 and antibiotic utilisation evaluated for 671,830 registered patients. The qualitative study included 31 patients and 30 health-care professionals from primary care.
Main outcome measures
Sepsis and localised bacterial infections.
Results
Patients were concerned about antimicrobial resistance and the side effects, as well as the benefits, of antibiotic treatment. Prescribers viewed the onset of sepsis as the most concerning potential outcome of reduced antibiotic prescribing. More than 40% of antibiotic prescriptions in primary care had no coded indication recorded across both Vision® and EMIS® practice systems. Antibiotic prescribing rates varied widely between general practices, but there was no evidence that serious bacterial infections were less frequent at higher prescribing practices (adjusted rate ratio for 20% increase in prescribing 1.03, 95% confidence interval 1.00 to 1.06; p = 0.074). The probability of sepsis was lower if an antibiotic was prescribed at an infection consultation, and the number of antibiotic prescriptions required to prevent one episode of sepsis (i.e. the number needed to treat) decreased with age. For those aged 0–4 years, the number needed to treat was 29,773 (95% uncertainty interval 18,458 to 71,091) in boys and 27,014 (95% uncertainty interval 16,739 to 65,709) in girls. For those aged > 85 years, the number needed to treat was 262 (95% uncertainty interval 236 to 293) in men and 385 (95% uncertainty interval 352 to 421) in women. Frailty was associated with a greater risk of sepsis and a smaller number needed to treat. For severely frail patients aged 55–64 years, the number needed to treat was 247 (95% uncertainty interval 156 to 459) for men and 343 (95% uncertainty interval 234 to 556) for women. At all ages, the probability of sepsis was greatest for urinary tract infection, followed by skin infection and respiratory tract infection. The numbers needed to treat were generally smaller for the period 2014–17, when sepsis was diagnosed more frequently. The results are available using an app that we developed to provide primary care prescribers with stratified risk estimates during infection consultations.
Limitations
Analyses were based on non-randomised comparisons. Infection episodes and antibiotic prescribing are poorly documented in primary care.
Conclusions
Antibiotic treatment is generally associated with lower risks, but the most serious bacterial infections remain infrequent even without antibiotic treatment. This research identifies risk strata in which antibiotic prescribing can be more safely reduced.
Future work
The software developed from this research may be further developed and investigated for antimicrobial stewardship effect.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 9. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Martin C Gulliford
- School of Population Health and Environmental Sciences, King’s College London, London, UK
- National Institute for Health Research Biomedical Research Centre, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Judith Charlton
- School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Olga Boiko
- School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Joanne R Winter
- School of Population Health and Environmental Sciences, King’s College London, London, UK
- National Institute for Health Research Biomedical Research Centre, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Emma Rezel-Potts
- School of Population Health and Environmental Sciences, King’s College London, London, UK
- National Institute for Health Research Biomedical Research Centre, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Xiaohui Sun
- School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Caroline Burgess
- School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Lisa McDermott
- School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Catey Bunce
- School of Population Health and Environmental Sciences, King’s College London, London, UK
- National Institute for Health Research Biomedical Research Centre, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - James Shearer
- School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Vasa Curcin
- School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Robin Fox
- Bicester Health Centre, Bicester, UK
| | - Alastair D Hay
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | - Paul Little
- Primary Care Research Group, University of Southampton, Southampton, UK
| | - Michael V Moore
- Primary Care Research Group, University of Southampton, Southampton, UK
| | - Mark Ashworth
- School of Population Health and Environmental Sciences, King’s College London, London, UK
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Arnolda G, Hiscock H, Moore D, Farrow G, Hibbert PD, Wiles LK, Ting HP, Molloy CJ, Warwick M, Braithwaite J. Assessing the appropriateness of the management of gastro-oesophageal reflux in Australian children: a population-based sample survey. Sci Rep 2021; 11:7744. [PMID: 33833360 PMCID: PMC8032666 DOI: 10.1038/s41598-021-87369-7] [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] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 03/25/2021] [Indexed: 11/23/2022] Open
Abstract
Gastro-oesophageal reflux (GOR) is a common physiological state in infants and young children, with gastro-oesophageal reflux disease (GORD) its pathological manifestation. Management of GOR/GORD requires elimination of possible underlying causes, parental reassurance, modification of feeding and symptom mitigation, monitoring, and referral to paediatricians if warning signs are present. Published clinical practice guidelines (CPGs) seek to support clinicians and improve management. This study aimed to measure the proportion of Australian GOR/GORD paediatric care that was in line with CPG recommendations. National and international CPGs for GOR/GORD were systematically identified and candidate indicators extracted; a Delphi process selected 32 indicators relevant to Australian paediatric care in 2012 and 2013. Medical records were identified in General Practices, the offices of general paediatricians, Emergency Departments and inpatient settings. Adherence to indicators was assessed by nine trained paediatric nurses undertaking retrospective medical record review. Medical records were reviewed in 115 healthcare sites; identifying 285 children, three-quarters aged < 1 year, who had 359 visits for management of GOR/GORD; 2250 eligible indicator assessments were performed. Estimated adherence rates are reported for 21 indicators with ≥ 25 assessments. Five indicators recommending differential diagnostic tests (e.g., urinalysis) for infants presenting with recurrent regurgitation and poor weight gain had ~ 10% adherence; conversely, avoidance of unrecommended tests (e.g., barium swallow and meal) was high (99.8% adherence: 95% CI 97.0-100). Avoidance of prescription of acid-suppression medication for infants at the first presentation was higher if they were healthy and thriving (86.9% adherence: 95% CI 86.0-96.8), intermediate if they had feeding refusal (73.1%: 95% CI 56.0-86.3) and lower if they presented with irritability and unexplained crying (58.8%: 95% CI 28.2-85.0). A guideline targeting Australian health professionals caring for infants and children with GOR/GORD is warranted, highlighting the importance of differential diagnostic testing and avoidance of acid-suppression medication in infants.
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Affiliation(s)
- Gaston Arnolda
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, Sydney, NSW, 2109, Australia.
| | - Harriet Hiscock
- Population Health Theme, Murdoch Children's Research Institute, Royal Children's Hospital, Flemington Road, Parkville, VIC, 3052, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, VIC, 3010, Australia
- School of Population and Global Health, The University of Melbourne, Melbourne, VIC, 3010, Australia
| | - David Moore
- Women's and Children's Hospital, 72 King William Road, North Adelaide, SA, 5006, Australia
| | - Glen Farrow
- Sydney Children's Hospital Network, Prince of Wales Hospital, High Street, Randwick, NSW, 2031, Australia
| | - Peter D Hibbert
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, Sydney, NSW, 2109, Australia
- Centre for Population Health Research, School of Health Sciences, University of South Australia, 101 Currie Street, Adelaide, SA, 5001, Australia
| | - Louise K Wiles
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, Sydney, NSW, 2109, Australia
- Centre for Population Health Research, School of Health Sciences, University of South Australia, 101 Currie Street, Adelaide, SA, 5001, Australia
| | - Hseun P Ting
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, Sydney, NSW, 2109, Australia
| | - Charlotte J Molloy
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, Sydney, NSW, 2109, Australia
- Centre for Population Health Research, School of Health Sciences, University of South Australia, 101 Currie Street, Adelaide, SA, 5001, Australia
| | - Meagan Warwick
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, Sydney, NSW, 2109, Australia
| | - Jeffrey Braithwaite
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, Sydney, NSW, 2109, Australia
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Should the interval between doses of antenatal corticosteroids be shortened in certain cases? Factors predicting preterm delivery < 48 h from presentation. Arch Gynecol Obstet 2021; 304:913-918. [PMID: 33782713 DOI: 10.1007/s00404-021-06032-8] [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: 08/20/2020] [Accepted: 03/12/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Treatment with antenatal corticosteroids (ACS) to women at risk for preterm birth (PTB) is associated with a reduction in adverse neonatal outcomes. Obstetricians occasionally shorten the interval between the doses of steroids if delivery is predicted to occur before ACS are fully administered. In this study, we aimed to investigate predicting factors to identify patients that will deliver prematurely, less than 48 h from presentation. METHODS The computerized medical files of all PTBs (< 34 weeks) were reviewed. Maternal demographics, pregnancy and delivery characteristics were compared between PTB that occurred < 48 h vs. > 48 h from triage presentation. RESULTS In total, 494 PTB cases were included: 302 women in the study group (PTB < 48 h) and 192 women in the control group (PTB > 48 h). No significant differences were found in demographic characteristics between the groups. At presentation, the study group had higher rates of uterine contractions (p < 0.001) and cervical length < 25 mm (p < 0.001) as well as a higher rate of non-reassuring fetal (NRFHR) monitor (p < 0.001). In contrast, the control group presented with higher rates of preeclampsia (p = 0.003) and preterm premature rupture of membranes (p = 0.038). In multivariable analysis, all of the above factors remained significant after controlling for background confounders. CONCLUSIONS Various factors at presentation can predict delivery < 48 h. These factors can be used to predict patients to whom the ACS interval should be shortened. Future prospective studies should investigate the effect of this shortening on neonatal outcomes.
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Saliba-Gustafsson EA, Nyberg A, Borg MA, Rosales-Klintz S, Stålsby Lundborg C. Barriers and facilitators to prudent antibiotic prescribing for acute respiratory tract infections: A qualitative study with general practitioners in Malta. PLoS One 2021; 16:e0246782. [PMID: 33571265 PMCID: PMC7877739 DOI: 10.1371/journal.pone.0246782] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 01/26/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Antibiotic resistance is a leading global public health concern and antibiotic use is a key driver. Effective interventions are needed to target key stakeholders, including general practitioners (GPs). In Malta, little is known about factors that influence GPs' antibiotic prescribing, making it challenging to implement targeted interventions. We therefore aimed to explore GPs' understanding of antibiotic use and resistance, and describe their perceived barriers and facilitators to prudent antibiotic prescribing for acute respiratory tract infections in Malta. METHODS Face-to-face individual semi-structured interviews were held with a quota sample of 20 GPs in 2014. Interviews were audio recorded and transcribed verbatim, and later analysed iteratively using manifest and latent content analysis. Findings were collated in a socioecological model to depict how GPs as individuals are embedded within larger social systems and contexts, and how each component within this system impacts their prescribing behaviour. FINDINGS We found that GPs' antibiotic prescribing decisions are complex and impacted by numerous barriers and facilitators at the individual, interpersonal, organisational, community, and public policy level. Predominant factors found to impact GPs' antibiotic prescribing included not only intrinsic GP factors such as knowledge, awareness, experience, and misconceptions, but also several external factors. At the interpersonal level, GPs' perceived patient demand and behaviour to be a persistent issue that impacts their prescribing decisions. Similarly, some GPs found pressure from drug reps to be concerning despite being considered an important source of information. Organisational and public policy-level issues such as lack of access to relevant antibiotic prescribing guidelines and current antibiotic resistance data from the community, were also considered major barriers to appropriate antibiotic prescribing. Utilisation of diagnostic testing was found to be low and GPs' perceptions on the introduction of rapid point-of-care tests to support antibiotic prescription decisions, were mixed. CONCLUSION This study revealed the complexity of the antibiotic prescribing decision and the numerous barriers and facilitators that impact it, visualised through a socioecological model. Addressing GPs' antibiotic prescribing practices will require targeted and coordinated implementation activities at all levels to change behaviour and address misconceptions, whilst also improving the physical and social environment. TRIAL REGISTRATION NUMBER NCT03218930; https://clinicaltrials.gov/ct2/show/NCT03218930.
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Affiliation(s)
- Erika A. Saliba-Gustafsson
- Department of Global Public Health, Health Systems and Policy (HSP): Improving Use of Medicines, Karolinska Institutet, Stockholm, Sweden
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California, United States of America
| | - Anna Nyberg
- Faculty of Social Sciences, Stockholm University, Stockholm, Sweden
| | - Michael A. Borg
- Department of Infection Prevention and Control, Mater Dei Hospital, Msida, Malta
- Faculty of Medicine and Surgery, University of Malta, Msida, Malta
| | - Senia Rosales-Klintz
- Department of Global Public Health, Health Systems and Policy (HSP): Improving Use of Medicines, Karolinska Institutet, Stockholm, Sweden
- Unit of Surveillance and Response Support (SRS), European Centre for Disease Prevention and Control, Solna, Sweden
| | - Cecilia Stålsby Lundborg
- Department of Global Public Health, Health Systems and Policy (HSP): Improving Use of Medicines, Karolinska Institutet, Stockholm, Sweden
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Education vs Clinician Feedback on Antibiotic Prescriptions for Acute Respiratory Infections in Telemedicine: a Randomized Controlled Trial. J Gen Intern Med 2021; 36:305-312. [PMID: 32845446 PMCID: PMC7878643 DOI: 10.1007/s11606-020-06134-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 08/11/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Antibiotics prescribed for acute respiratory tract infections in the telemedicine setting are often unwarranted. OBJECTIVE We hypothesized that education plus individualized feedback, compared with education alone, would significantly reduce antibiotic prescription rates for upper respiratory infections, bronchitis, sinusitis, and pharyngitis in a telemedicine setting. DESIGN Two-arm, parallel-group randomized controlled trial conducted at a telemedicine practice from January 1, 2018, to November 30, 2018. PARTICIPANTS Clinicians employed at the practice on or after January 1, 2017 (n = 45). INTERVENTIONS The control group received education (treatment guideline presentation and online course) in April 2018. The intervention group received education plus individualized feedback via an online dashboard with monthly rates of personal and practice-wide antibiotic prescription rates starting May 2018. MAIN MEASURES Antibiotic prescription for any visit with at least one target condition: upper respiratory tract infection, bronchitis, sinusitis, and pharyngitis. KEY RESULTS Baseline antibiotic prescription rates in control and intervention groups across conditions were as follows: upper respiratory infection (URI): 626/3410 (18.4%), 413/2752 (15.0%), bronchitis: 689/1471 (46.8%), 742/1162 (64.0%), sinusitis: 5154/6131 (84.1%), 4250/4876 (87.2%), pharyngitis: 2308/2838 (81.3%), 1593/2126 (74.9%). Antibiotic prescriptions for all conditions decreased in the post-intervention period compared with those in the pre-intervention period, for both control and intervention groups. Reduction of antibiotic prescriptions for URI and bronchitis was greater for the group receiving education plus individualized feedback compared with that for the group receiving education alone (interaction term ratio 0.60, 95% CI 0.47 to 0.77 for URI; and interaction term ratio 0.42, 95% CI 0.32 to 0.55 for bronchitis), but not sinusitis and pharyngitis. CONCLUSION Education plus individualized feedback in a telemedicine practice significantly decreased antibiotic prescription rates for upper respiratory tract infections and bronchitis, compared with education alone. Future studies should focus on tailoring antibiotic stewardship programs based on underlying conditions, and the maintenance of early reductions in antibiotic prescription.
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48
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Borek AJ, Campbell A, Dent E, Butler CC, Holmes A, Moore M, Walker AS, McLeod M, Tonkin-Crine S. Implementing interventions to reduce antibiotic use: a qualitative study in high-prescribing practices. BMC FAMILY PRACTICE 2021; 22:25. [PMID: 33485324 PMCID: PMC7825381 DOI: 10.1186/s12875-021-01371-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 01/09/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Trials have shown that delayed antibiotic prescriptions (DPs) and point-of-care C-Reactive Protein testing (POC-CRPT) are effective in reducing antibiotic use in general practice, but these were not typically implemented in high-prescribing practices. We aimed to explore views of professionals from high-prescribing practices about uptake and implementation of DPs and POC-CRPT to reduce antibiotic use. METHODS This was a qualitative focus group study in English general practices. The highest antibiotic prescribing practices in the West Midlands were invited to participate. Clinical and non-clinical professionals attended focus groups co-facilitated by two researchers. Focus groups were audio-recorded, transcribed verbatim and analysed thematically. RESULTS Nine practices (50 professionals) participated. Four main themes were identified. Compatibility of strategies with clinical roles and experience - participants viewed the strategies as having limited value as 'clinical tools', perceiving them as useful only in 'rare' instances of clinical uncertainty and/or for those less experienced. Strategies as 'social tools' - participants perceived the strategies as helpful for negotiating treatment decisions and educating patients, particularly those expecting antibiotics. Ambiguities - participants perceived ambiguities around when they should be used, and about their impact on antibiotic use. Influence of context - various other situational and practical issues were raised with implementing the strategies. CONCLUSIONS High-prescribing practices do not view DPs and POC-CRPT as sufficiently useful 'clinical tools' in a way which corresponds to the current policy approach advocating their use to reduce clinical uncertainty and improve antimicrobial stewardship. Instead, policy attention should focus on how these strategies may instead be used as 'social tools' to reduce unnecessary antibiotic use. Attention should also focus on the many ambiguities (concerns and questions) about, and contextual barriers to, using these strategies that need addressing to support wider and more consistent implementation.
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Affiliation(s)
- Aleksandra J Borek
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.
| | - Anne Campbell
- National Institute for Health Research (NIHR) Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
| | - Elle Dent
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, 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
| | - Michael Moore
- Primary Care Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton, UK
| | - A Sarah Walker
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK.,NIHR Oxford Biomedical Research Centre, Oxford, UK.,Nuffield Department of Medicine, 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, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.,NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
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Ślęzak K, Dembiński Ł, Konefał A, Dąbrowski M, Mazur A, Peregud-Pogorzelska M, Wawrykow P, Konefał D, Peregud-Pogorzelski J. Impact of Selected Behavioral and Environmental Factors on the Antibiotic Therapy in Polish Children With Upper Respiratory Tract Infections. Front Pediatr 2021; 9:784265. [PMID: 34926354 PMCID: PMC8678461 DOI: 10.3389/fped.2021.784265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 11/08/2021] [Indexed: 11/13/2022] Open
Abstract
Antibiotic therapy must be carried out consistently and according to the guidelines. Viruses are the dominant cause of upper respiratory tract infections (URTIs) in children, as has been shown in many previous studies. Unnecessary antibiotic therapy should be avoided so that it does not affect patients' health and lead to the development of resistant bacterial strains. Here we report a national survey conducted in a group of 4,389 children to assess the impact of selected behavioral and environmental factors on antibiotic therapy in patients with URTIs. We found that selected environmental factors influenced the type of treatment. The place of residence, having siblings, an absence of vaccinations, the presence of allergies, and attendance at educational institutions were conducive to antibiotic therapy. These factors also influenced the frequency of hospitalization of children and their absence from nurseries, kindergartens, and schools, as well as the absence of their guardians from work.
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Affiliation(s)
- Katarzyna Ślęzak
- Department of Pediatrics, Pediatric Oncology and Immunology, Pomeranian Medical University, Szczecin, Poland
| | - Łukasz Dembiński
- Department of Pediatric Gastroenterology and Nutrition, Medical University of Warsaw, Warsaw, Poland
| | | | - Mikołaj Dąbrowski
- Adult Spine Orthopaedics Department, Poznan University of Medical Sciences, Poznań, Poland
| | - Artur Mazur
- Department of Pediatrics, Pediatric Endocrinology and Diabetes, Medical College of Rzeszow University, Rzeszów, Poland
| | | | - Paweł Wawrykow
- Department of Pediatrics, Pediatric Oncology and Immunology, Pomeranian Medical University, Szczecin, Poland
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50
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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.
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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
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