Categorical Risk Perception Drives Variability in Antibiotic Prescribing in the Emergency Department: A Mixed Methods Observational Study

Racial and Socioeconomic Disparities Evident in Inappropriate Antibiotic Prescribing in the Emergency Department

STUDY OBJECTIVE

Inappropriate antibiotic prescribing for acute respiratory tract infections is a common source of low-value care in the emergency department (ED). Racial and socioeconomic disparities have been noted in episodes of low-value care, particularly in children. We evaluated whether prescribing rates for acute respiratory tract infections when antibiotics would be inappropriate by guidelines differed by race and socioeconomics.

METHODS

A retrospective cross-sectional analysis of adult and pediatric patient encounters in the emergency department (ED) between 2015 and 2023 at 5 hospitals for acute respiratory tract infections that did not require antibiotics by guidelines. Multivariable regression was used to calculate the risk ratio between race, ethnicity, and area deprivation index and inappropriate antibiotic prescribing, controlling for patient age, sex, and relevant comorbidities.

RESULTS

A total of 147,401 ED encounters (55% pediatric, 45% adult) were included. At arrival, 4% patients identified as Asian, 50% as Black, 5% as Hispanic, and 23% as White. Inappropriate prescribing was noted in 7.6% of overall encounters, 8% for Asian patients, 6% for Black patients, 5% for Hispanic patients, and 12% for White patients. After adjusting for age, sex, comorbidities, and area deprivation index, White patients had a 1.32 (95% confidence interval, 1.26 to 1.38) higher likelihood of receiving a prescription compared with Black patients. Patients residing in areas of greater socioeconomic deprivation, regardless of race and ethnicity, had a 0.74 (95% confidence interval, 0.70 to 0.78) lower likelihood of receiving a prescription.

CONCLUSION

Our results suggest that although overall inappropriate prescribing was relatively low, White patients and patients from wealthier areas were more likely to receive an inappropriate antibiotic prescription.

A confirmation of the predictive utility of the Antibiotic Use Questionnaire

BACKGROUND

The change in the efficacy of antimicrobial agents due to their misuse is implicated in extensive health and mortality related concerns. The Antibiotics Use Questionnaire (AUQ) is a theory driven measure based on the Theory of Planned Behaviour (TpB) factors that is designed to investigate drivers of antibiotic use behaviour. The objective of this study is to replicate the factor structure from the pilot study within a similar Australian confirmation cohort, and to extend this through investigating if the factor structure holds in a Chinese-identifying cohort.

METHODS

The AUQ was disseminated to two cohorts: a confirmation cohort similar to the original study, and a Chinese identifying cohort. Data analysis was completed on the two data sets independently, and on a combined data set. An orthogonal principal components analysis with varimax rotation was used to assess the factor structure, followed by general linear models to determine the influence of the TpB factors on reported antibiotic use.

RESULTS

370 participant responses from the confirmation cohort, and 384 responses from the Chinese-identifying cohort were retained for analysis following review of the data. Results showed modest but acceptable levels of internal reliability across both cohorts. Social norms, and the interaction between attitudes and beliefs and knowledge were significant predictors of self-reported antibiotic use in both cohorts. In the confirmation cohort healthcare training was a significant predictor, and in the Chinese-identifying cohort education was a significant predictor. All other predictors tested produced a nonsignificant relationship with the outcome variable of self-reported antibiotic use.

CONCLUSIONS

This study successfully replicated the factor structure of the AUQ in a confirmation cohort, as well as a cohort that identified as culturally or legally Chinese, determining that the factor structure is retained when investigated across cultures. The research additionally highlights the need for a measure such as the AUQ, which can identify how differing social, cultural, and community factors can influence what predicts indiscriminate antibiotic use. Future research will be required to determine the full extent to which this tool can be used to guide bespoke community level interventions to assist in the management of antimicrobial resistance.

Perceptions of antibiotic resistance among hospital healthcare professionals in high-income countries: A systematic review of causes, consequences, and solutions

OBJECTIVE

Antibiotic resistance (ABR) is a major threat to public health. Hospital healthcare professionals are important stakeholders in curbing ABR. To be able to encourage healthcare professionals to act against ABR, information on their perceptions is needed. Yet, summary evidence on how healthcare professionals perceive ABR causes, consequences, and solutions is outdated. This review aims to elucidate these perceptions.

METHODS

We searched MEDLINE, EMBASE, PsycINFO, and CINAHL for literature published until July 6th, 2022, and used Web of Science and Scopus to identify reports citing included studies. Reports of quantitative original research from high-income countries were included if they investigated hospital healthcare professionals' perceptions about ABR. Descriptive data and data on perceptions about causes, consequences, and solutions regarding ABR were extracted. PROSPERO registration: CRD42022359249.

RESULTS

The database search and citation tracking yielded 13,551 and 694 papers respectively. Forty-eight reports from 46 studies were included in the review. These studies were performed between 1999 and 2023 and included between 8 and 1362 participants. Healthcare professionals perceived ABR as a problem that is more severe nationally than locally and they primarily recognize ABR as a distant and abstract problem. Studies mostly concurred on prescribing behavior as a cause and a solution for ABR, while external causes and solutions (e.g., in agriculture) elicited less agreement.

CONCLUSIONS

Studies with a primary focus on the perceptions of healthcare professionals about ABR are limited. Healthcare professionals perceive prescribing behavior as a major cause of ABR and a focus area for ABR solutions.

Parent and Clinician Views on Not Using Antibiotics for Mild Community-Acquired Pneumonia

OBJECTIVES

Preschool-aged children with mild community-acquired pneumonia (CAP) routinely receive antibiotics even though most infections are viral. We sought to identify barriers to the implementation of a "no antibiotic" strategy for mild CAP in young children.

METHODS

Qualitative study using semistructured interviews conducted in a large pediatric hospital in the United States from January 2021 to July 2021. Parents of young children diagnosed with mild CAP in the previous 3 years and clinicians practicing in outpatient settings (pediatric emergency department, community emergency department, general pediatrics offices) were included.

RESULTS

Interviews were conducted with 38 respondents (18 parents, 20 clinicians). No parent heard of the no antibiotic strategy, and parents varied in their support for the approach. Degree of support related to their desire to avoid unnecessary medications, trust in clinicians, the emotional difficulty of caring for a sick child, desire for relief of suffering, willingness to accept the risk of unnecessary antibiotics, and judgment about the child's illness severity. Eleven (55%) clinicians were familiar with guidelines specifying a no antibiotic strategy. They identified challenges in not using antibiotics, including diagnostic uncertainty, consequences of undertreatment, parental expectations, follow-up concerns, and acceptance of the risks of unnecessary antibiotic treatment of many children if it means avoiding adverse outcomes for some children.

CONCLUSIONS

Although both parents and clinicians expressed broad support for the judicious use of antibiotics, pneumonia presents stewardship challenges. Interventions will need to consider the emotional, social, and logistical aspects of managing pneumonia, in addition to developing techniques to improve diagnosis.

Uncovering doctors' perceived barriers and facilitators of antibiotic prescribing behaviours: a qualitative study using the theoretical domains framework

BACKGROUND AND AIM OF THE WORK

Uncovering the barriers and facilitators of antibiotic prescribing is crucial in order to develop effective strategies for promoting responsible and evidence-based antibiotic use, thereby combating antibiotic resistance and enhancing patient care. This qualitative study, informed by the Theoretical Domains Framework (TDF) - specifically designed to understand and analyze the factors that influence human behavior, with a focus on identifying barriers and facilitators to behavior change, was aimed to explore the determinants (barriers and facilitators) of antibiotic prescribing behaviors from the perspective of doctors.

RESEARCH DESIGN AND METHODS

Semi-structured interviews were conducted with healthcare professionals, and data analysis followed a theory-driven approach guided by the TDF.

RESULTS

The analysis identified eight TDF domains influencing antibiotic prescribing, including memory, attention, and decision processes; knowledge; skills; belief about capabilities; goals; belief about consequences; emotions; and environmental context and resources. These domains were clustered into three overarching themes according to a bottom-up logic: the decision-making prescribing process itself, intrinsic factors related to the physician, and extrinsic factors influencing the decision.

CONCLUSIONS

This research provides a comprehensive understanding of the complex interactions between these determinants in antibiotic prescribing. The evidence gained from the study valuable information for developing targeted interventions to improve antibiotic prescribing practices and combat antimicrobial resistance considering psychosocial and environmental variables impacting on antibiotic prescription decision making.

Can degrading information about patient symptoms in vignettes alter clinical reasoning in paramedics and paramedic students? An experimental application of fuzzy trace theory

BACKGROUND

Research has shown paramedics form rapid intuitive impressions on first, meeting a patient and these impressions subsequently affected their clinical reasoning. We report an experiment where theory-based interventions are developed with the goal of reducing reliance on intuitive reasoning by paramedics and paramedic students in simulated patients.

METHOD

Australian paramedics (n = 213; 49% female) and paramedicine students (n = 83; 55% female) attending paramedic conferences completed a 2 × 2 fully between participants experiment. They saw a written clinical vignette designed to be representative of Acute Coronary Syndrome (ACS) in which key clinical information was precise or degraded (stimulus), they then either chose the single most likely diagnosis from a list, or ranked competing diagnoses (response). Outcome variables were diagnostic rate and response time.

RESULTS

There were no differences in the proportion of participants choosing ACS across the four stimulus-response conditions (0.75 [0.65, 0.84] vs 0.79 [0.68, 0.87] vs, 0.78 [0.65, 0.87] vs 0.72 [0.59, 0.82], p = 0.42) CONCLUSION: This is the first study attempting to experimentally examine clinical reasoning in paramedics using a theory-based intervention. Neither of the interventions tested succeeded in altering measures of clinical reasoning. Similar to previous research on physicians, paramedic reasoning appears robust to manipulation.

What works for and what hinders deimplementation of low-value care in emergency medicine practice? A scoping review

OBJECTIVES

Low-value care can harm patients and healthcare systems. Despite a decade of global endeavours, low value care has persisted. Identification of barriers and enablers is essential for effective deimplementation of low-value care. This scoping review is an evidence summary of barriers, enablers and features of effective interventions for deimplementation of low-value care in emergency medicine practice worldwide.

DESIGN

A mixed-methods scoping review was conducted using the Arksey and O'Malley framework.

DATA SOURCES

Medline, CINAHL, Embase, EMCare, Scopus and grey literature were searched from inception to 5 December 2022.

ELIGIBILITY CRITERIA

Primary studies which employed qualitative, quantitative or mixed-methods approaches to explore deimplementation of low-value care in an EM setting and reported barriers, enablers or interventions were included. Reviews, protocols, perspectives, comments, opinions, editorials, letters to editors, news articles, books, chapters, policies, guidelines and animal studies were excluded. No language limits were applied.

DATA EXTRACTION AND SYNTHESIS

Study selection, data collection and quality assessment were performed by two independent reviewers. Barriers, enablers and interventions were mapped to the domains of the Theoretical Domains Framework. The Mixed Methods Appraisal Tool was used for quality assessment.

RESULTS

The search yielded 167 studies. A majority were quantitative studies (90%, 150/167) that evaluated interventions (86%, 143/167). Limited provider abilities, diagnostic uncertainty, lack of provider insight, time constraints, fear of litigation, and patient expectations were the key barriers. Enablers included leadership commitment, provider engagement, provider training, performance feedback to providers and shared decision-making with patients. Interventions included one or more of the following facets: education, stakeholder engagement, audit and feedback, clinical decision support, nudge, clinical champions and training. Multifaceted interventions were more likely to be effective than single-faceted interventions. Effectiveness of multifaceted interventions was influenced by fidelity of the intervention facets. Use of behavioural change theories such as the Theoretical Domains Framework in the published studies appeared to enhance the effectiveness of interventions to deimplement low-value care.

CONCLUSION

High-fidelity, multifaceted interventions that incorporated education, stakeholder engagement, audit/feedback and clinical decision support, were administered daily and lasted longer than 1 year were most effective in achieving deimplementation of low-value care in emergency departments. This review contributes the best available evidence to date, but further rigorous, theory-informed, qualitative and mixed-methods studies are needed to supplement the growing body of evidence to effectively deimplement low-value care in emergency medicine practice.

Point-of-care multiplex molecular diagnosis coupled with procalcitonin-guided algorithm for antibiotic stewardship in lower respiratory tract infection: a randomized controlled trial

OBJECTIVE

We aimed to show that coupling molecular syndromic respiratory panel (RP) testing with procalcitonin (PCT) measurement in the emergency department improves antibiotic (ATB) stewardship in lower respiratory tract infection.

METHODS

Open-label, prospective, randomized interventional trial, conducted from 2019 to 2022 in an adult emergency department. Patients with a suspicion of lower respiratory tract infection were randomized into an intervention arm (PCT measurement and point-of-care BIOFIRE RP2.1 plus testing, accompanied by a recommended ATB algorithm) or a standard of care (SOC) arm (PCT allowed as current practice). The primary endpoint was the duration of antibiotic exposure.

RESULTS

Four hundred fifty-one patients were randomized, median age 65 years (Q1-Q3: 49-77), the hospitalization rate was 59.9% (270/451), the median length of stay 5 days (Q1-Q3: 3 - 12), and the 28-day mortality rate 5.3% (23/451). The median duration of ATB exposure was 6 days (Q1-Q3: 0-9) and 5 days (Q1-Q3: 0-9) in the SOC and interventional arm respectively (p = 0.71). ATB was started in 29.6 % (67/226) and 33.8% (76/225) respectively (p = 0.54). The BIOFIRE RP2.1 plus identified at least one viral species in 112/225 patients (49.8%) of intervention arm. Two hundred twelve out of two hundred twenty-six (93.8%) SOC patients had PCT measurement. The adherence rate to algorithm in the intervention arm was 93.3 % (210/225).

CONCLUSION

Displaying PCT and real-time RP results to emergency physicians failed to significantly reduce ATB exposure in lower respiratory tract infection suspicions. However, the median ATB duration and rate of initiation were already low in the SOC arm using PCT measurement routinely.

Evaluating the long-term portrayal of antibiotic resistance in major U.S. newspapers

BACKGROUND

Popular media play a critical role in informing the public about antibiotic resistance, which has remained a health concern for over seven decades. Media attention increases the notoriety of antibiotic resistance and shapes the public's perception of its severity, causes, and solutions. Therefore, it is critical the media accurately portray scientific knowledge that may shape personal and policy responses to antibiotic resistance.

METHODS

We analyzed articles from two major U.S. newspapers, The New York Times and Los Angeles Times, from 1940 to 2019 to assess trends in sentiment and lexicon surrounding antibiotic and antimicrobial resistance.

RESULTS

We observed a gradual increase in the number of relevant articles about resistance, although far fewer than other topics with comparable mortality rates. We found a consistently threatening portrayal of antibiotic resistance as a crisis, reflected in the usage of terms such as "superbug" to refer to some pathogens. Governmental agencies responsible for determining antibiotic usage policies were infrequently mentioned in articles. Blame for resistance was almost exclusively attributed to inappropriate antibiotic use, mainly in animals, rather than appropriate uses of antibiotics.

CONCLUSIONS

Collectively, our results provide insights into how popular media can more accurately inform the public about antibiotic resistance. Potential changes include increasing news coverage, avoiding fear-mongering, and adequately conveying the multiple uses of antibiotics that can potentiate resistance.

A scoping review and behavioural analysis of factors underlying overuse of antimicrobials

Background

Overuse of antimicrobials is a challenging global issue that contributes to antimicrobial resistance. Despite widespread awareness of the problem among members of the medical community and various attempts to improve prescription practices, existing antimicrobial stewardship programmes are not always effective. In our view, this may reflect limited understanding of factors that influence prescription of antimicrobials as empirical therapy, implying a need to address the psychological mechanisms behind some of the specific behaviours involved.

Objectives

To identify factors that influence the antimicrobials prescription as empirical therapy, and to relate these factors to findings from behavioural science.

Methods

We conducted a scoping review of the literature on the factors underlying antimicrobial prescription decisions, following the protocol designed using PRISMA guidelines.

Results and conclusions

From a final sample of 90 sources, we identified ten factors important in antimicrobial prescription decisions. In the second stage of our analysis, we grouped them into five final categories: (1) nature of the decision, (2) social influences, (3) individual differences, (4) characteristics of the patient, (5) context. We analyse these categories using a behavioural science perspective.

Low Mortality among Under-5 Children with Severe Community-Acquired Pneumonia: A 5-Year Retrospective Analysis of 588 Admissions in Ibadan, Nigeria

Objective Community-acquired pneumonia (CAP) is the commonest cause of death in under-5 children worldwide. Although the mortality from CAP has decreased over the last decade, it is still unacceptably high in lower-middle-income countries (LMICs). We aimed to determine the case fatality rate (CFR), and factors associated with treatment failure and outcome, using recommended antimicrobials.

Methods A 5-year retrospective review of severe pediatric pneumonia admissions between August 1st, 2014 and July 31st, 2019 at the University College Hospital, Ibadan, Nigeria was conducted. Relevant clinical information including antibiotics use and outcome was analyzed using descriptive statistics, test of association, and logistic regression.

Results There were 588 children aged 2 to 59 months, male:female ratio was 1.5:1. About two-thirds were aged ≤12 months. The majority were fully immunized for age (87.2%), about 34% were malnourished and 68% were hypoxemic at presentation. Only 71% of children were commenced on the recommended first-line antibiotics following the Pediatric Association of Nigeria (PAN) antibiotic guidelines. Initial antibiotics were changed in 22.3% of the patients. The need to change intravenous (iv) amoxicillin plus iv gentamicin was necessary in 23.80% compared with 18.1% for iv cefuroxime plus iv gentamicin. Severe acute malnutrition (odds ratio [OR]: 2.8 [95% confidence interval [CI]: 1.1–7.3]) and hypoxemia (OR:2.3 [95%CI: 1.0–5.6]) were independently associated with antibiotics change. The CFR was 1.36%.

Conclusion The low CFR suggests a better outcome compared with other previous studies in LMICs. However, the high rate of antibiotics changes (22.3%) was possibly due to failure of first line antibiotics; especially among malnourished and hypoxemic children. Randomized controlled trial of iv cefuroxime plus gentamicin versus iv amoxicillin plus gentamicin is recommended.

Supporting Health and Medical Decision Making: Findings and Insights from Fuzzy-Trace Theory

HIGHLIGHTS

Fuzzy-trace theory (FTT) supports practical approaches to improving health and medicine.FTT differs in important respects from other theories of decision making, which has implications for how to help patients, providers, and health communicators.Gist mental representations emphasize categorical distinctions, reflect understanding in context, and help cue values relevant to health and patient care.Understanding the science behind theory is crucial for evidence-based medicine.

Top Myths of Diagnosis and Management of Infectious Diseases in Hospital Medicine

Antimicrobial agents are among the most frequently prescribed medications during hospitalization. However, approximately 30% to 50% or more of inpatient antimicrobial use is unnecessary or suboptimal. Herein, we describe 10 common myths of diagnosis and management that often occur in the hospital setting. Further, we discuss supporting data to dispel each of these myths. This analysis will provide hospitalists and other clinicians with a foundation for rational decision-making about antimicrobial use and support antimicrobial stewardship efforts at both the patient and institutional levels.

Gist Representations and Decision-Making Processes Affecting Antibiotic Prescribing for Children with Acute Otitis Media

Objective. To test the predictions of fuzzy-trace theory regarding pediatric clinicians’ decision-making processes and risk perceptions about antibiotics for children with acute otitis media (AOM). Methods. We conducted an online survey experiment administered to a sample of 260 pediatric clinicians. We measured their risk perceptions and prescribing decisions across 3 hypothetical AOM treatment scenarios. Participants were asked to choose among the following options: prescribe antibiotics immediately, watchful waiting (“hedging”), or not prescribing antibiotics. Results. We identified 4 gists based on prior literature: 1) “why not take a risk?” 2) “antibiotics might not help but can hurt,” 3) “antibiotics do not have harmful side effects,” and 4) “antibiotics might have harmful side effects.” All 4 gists predicted risky choice (P < 0.001), and gist endorsements varied significantly between scenarios when antibiotics were indicated, F(2, 255) = 8.53, P < 0.001; F(2, 255) = 5.14, P < .01; and F(2, 255) = 3.56, P < 0.05 for the first 3 factors, respectively. In a logistic regression, more experienced clinicians were less likely to hedge (B = −0.05; P < 0.01). Conclusion. As predicted by fuzzy-trace theory, pediatric clinicians’ prescription decisions are associated with gist representations, which are distinct from verbatim risk estimates. Implications. Antibiotic stewardship programs can benefit by communicating the appropriate gists to clinicians who prescribe antibiotics for pediatric patients.

Efficacy of Care and Antibiotic Use for Chalazia and Hordeola

OBJECTIVES

To evaluate whether use of an antibiotic improves the efficacy of care for a chalazion or hordeolum.

METHODS

A cross-sectional retrospective review was performed. All patients treated for a newly diagnosed chalazion or hordeolum at the University of California, San Francisco from 2012 to 2018 were identified. Patients were excluded when clinical notes were inaccessible or there was inadequate documentation of treatment modality or outcome. Patient demographics, setting of initial presentation, treatment modalities, antibiotic use, and outcomes were analyzed.

RESULTS

A total of 2,712 patients met inclusion criteria. Management with an antibiotic was observed in 36.5% of patients. An antibiotic was 1.53 times (95% confidence interval [CI], 1.06-2.22, P=0.025) more likely to be prescribed in emergency or acute care setting for a chalazion. Older age was associated with a higher risk of receiving an antibiotic for a hordeolum (adjusted RR 1.07 per decade, 95% CI, 1.05-1.11, P<0.001). The addition of an antibiotic to conservative measures for a chalazion (adjusted RR, 0.97, 95% CI, 0.89-1.04, P=0.393) or hordeolum (adjusted RR, 0.99, 95% CI, 0.96-1.02, P=0.489) was not associated with an increased likelihood of treatment success.

CONCLUSION

Although frequently prescribed, an antibiotic is unlikely to improve the resolution of a chalazion or hordeolum.

Using theories and frameworks to understand how to reduce low-value healthcare: a scoping review

BACKGROUND

There is recognition that the overuse of procedures, testing, and medications constitutes low-value care which strains the healthcare system and, in some circumstances, can cause unnecessary stress and harm for patients. Initiatives across dozens of countries have raised awareness about the harms of low-value care but have had mixed success and the levels of reductions realized have been modest. Similar to the complex drivers of implementation processes, there is a limited understanding of the individual and social behavioral aspects of de-implementation. While researchers have begun to use theory to elucidate the dynamics of de-implementation, the research remains largely atheoretical. The use of theory supports the understanding of how and why interventions succeed or fail and what key factors predict success. The purpose of this scoping review was to identify and characterize the use of theoretical approaches used to understand and/or explain what influences efforts to reduce low-value care.

METHODS

We conducted a review of MEDLINE, EMBASE, CINAHL, and Scopus databases from inception to June 2021. Building on previous research, 43 key terms were used to search the literature. The database searches identified 1998 unique articles for which titles and abstracts were screened for inclusion; 232 items were selected for full-text review.

RESULTS

Forty-eight studies met the inclusion criteria. Over half of the included articles were published in the last 2 years. The Theoretical Domains Framework (TDF) was the most commonly used determinant framework (n = 22). Of studies that used classic theories, the majority used the Theory of Planned Behavior (n = 6). For implementation theories, Normalization Process Theory and COM-B were used (n = 7). Theories or frameworks were used primarily to identify determinants (n = 37) and inform data analysis (n = 31). Eleven types of low-value care were examined in the included studies, with prescribing practices (e.g., overuse, polypharmacy, and appropriate prescribing) targeted most frequently.

CONCLUSIONS

This scoping review provides a rigorous, comprehensive, and extensive synthesis of theoretical approaches used to understand and/or explain what factors influence efforts to reduce low-value care. The results of this review can provide direction and insight for future primary research to support de-implementation and the reduction of low-value care.

Viruses, Vaccines, and COVID-19: Explaining and Improving Risky Decision-making

Risky decision-making lies at the center of the COVID-19 pandemic and will determine future viral outbreaks. Therefore, a critical evaluation of major explanations of such decision-making is of acute practical importance. We review the underlying mechanisms and predictions offered by expectancy-value and dual-process theories. We then highlight how fuzzy-trace theory builds on these approaches and provides further insight into how knowledge, emotions, values, and metacognitive inhibition influence risky decision-making through its unique mental representational architecture (i.e., parallel verbatim and gist representations of information). We discuss how social values relate to decision-making according to fuzzy-trace theory, including how categorical gist representations cue core values. Although gist often supports health-promoting behaviors such as vaccination, social distancing, and mask-wearing, why this is not always the case as with status-quo gist is explained, and suggestions are offered for how to overcome the "battle for the gist" as it plays out in social media.

Behavioral Economics and Ambulatory Antibiotic Stewardship: A Narrative Review

PURPOSE

Behavioral economics recognizes that contextual, psychological, social, and emotional factors powerfully influence decision-making. Behavioral economics has the potential to provide a better understanding of, and, through subtle environmental changes, or "nudges," improve persistent quality-of-care challenges, like ambulatory antibiotic overprescribing. Despite decades of admonitions and educational initiatives, in the United States, up to 50% of ambulatory antibiotic prescriptions remain inappropriate or not associated with a diagnosis.

METHODS

We conducted a Medline search and performed a narrative review that examined the use of behavioral economics to understand the rationale for, and improvement of, ambulatory antibiotic prescribing.

FINDINGS

Clinicians prescribe antibiotics inappropriately because of perceived patient demand, to maintain patient satisfaction, diagnostic uncertainty, or time pressure, among other reasons. Behavioral economics-informed approaches offer additional improvements in antibiotic prescribing beyond clinician education and communication training. Precommitment, in which clinicians publicize their intent to prescribe antibiotics "only when they are absolutely necessary," leverages clinicians' self-conception and a desire to act in a manner consistent with public statements. Precommitment was associated with a 20% absolute reduction in the inappropriate antibiotic prescribing for acute respiratory infections. Justification alerts, in which clinicians must provide a brief written rationale for prescribing antibiotics, leverages social accountability, redefines the status quo as an active choice, and helps clinicians to shift from fast to slow, careful thinking. With justification alerts, the absolute rate of inappropriate antibiotic prescribing decreased from 23% to 5%. Peer comparison, in which clinicians receive feedback comparing their performance to their top-performing peers, provides evidence of improved performance and leverages peoples' desire to conform to social norms. Peer comparison decreased absolute inappropriate antibiotic prescribing rates from 20% to 4%, a decrease that persisted for 12 months after the end of the intervention. Also, a one-time peer-comparison letter from a high-profile messenger to primary care practices with high rates of prescribing antibiotics, there was a 6-month, 3% decrease inantibiotic prescribing. Future directions in applying behavioral economics to the inappropriate antibiotic prescribing include paying careful attention to design details; improving intervention effectiveness and durability; making harms salient; participants' involvement in the development of interventions (the "Ikea effect"); factoring in patient satisfaction; and patient-facing nudges about antibiotic use and care-seeking. In addition, the COVID pandemic could aid in ambulatory antibiotic prescribing improvements due to changing cognitive frames around respiratory symptom evaluation and antibiotic prescribing.

IMPLICATIONS

To improve ambulatory antibiotic prescribing, several behavioral economics-informed approaches-especially precommitment, justification alerts, and peer comparison-have reduced the rates of inappropriate prescribing of antibiotics to low levels.

Questioning the Yelp Effect: Mixed Methods Analysis of Web-Based Reviews of Urgent Cares

Background

Providers of on-demand care, such as those in urgent care centers, may prescribe antibiotics unnecessarily because they fear receiving negative reviews on web-based platforms from unsatisfied patients—the so-called Yelp effect. This effect is hypothesized to be a significant driver of inappropriate antibiotic prescribing, which exacerbates antibiotic resistance.

Objective

In this study, we aimed to determine the frequency with which patients left negative reviews on web-based platforms after they expected to receive antibiotics in an urgent care setting but did not.

Methods

We obtained a list of 8662 urgent care facilities from the Yelp application programming interface. By using this list, we automatically collected 481,825 web-based reviews from Google Maps between January 21 and February 10, 2019. We used machine learning algorithms to summarize the contents of these reviews. Additionally, 200 randomly sampled reviews were analyzed by 4 annotators to verify the types of messages present and whether they were consistent with the Yelp effect.

Results

We collected 481,825 reviews, of which 1696 (95% CI 1240-2152) exhibited the Yelp effect. Negative reviews primarily identified operations issues regarding wait times, rude staff, billing, and communication.

Conclusions

Urgent care patients rarely express expectations for antibiotics in negative web-based reviews. Thus, our findings do not support an association between a lack of antibiotic prescriptions and negative web-based reviews. Rather, patients’ dissatisfaction with urgent care was most strongly linked to operations issues that were not related to the clinical management plan.

Health emergencies and interoceptive sensibility modulate the perception of non-evidence-based drug use: Findings from the COVID-19 outbreak

Scientific evidence plays an important role in the therapeutic decision-making process. What happens when physicians are forced to make therapeutic decisions under uncertainty? The absence of scientific guidelines at the beginning of a pandemic due to an unknown virus, such as COVID-19, could influence the perceived legitimacy of the application of non-evidence-based therapeutic approaches. This paper reports on a test of this hypothesis, in which we administered an ad hoc questionnaire to a sample of 64 Italian physicians during the first wave of the COVID-19 pandemic in Italy (April 2020). The questionnaire statements regarding the legitimacy of off-label or experimental drugs were framed according to three different scenarios (Normality, Emergency and COVID-19). Furthermore, as the perception of internal bodily sensations (i.e., interoception) modulates the decision-making process, we tested participants' interoceptive sensibility using the Multidimensional Assessment of Interoceptive Awareness (MAIA). The results showed that participants were more inclined to legitimate non-evidence-based therapeutic approaches in the COVID-19 and Emergency scenarios than the Normality scenario. We also found that scores on the MAIA Trusting subscale positively predicted this difference. Our findings demonstrate that uncertain medical scenarios, involving a dramatic increase in patient volume and acuity, can increase risk-taking in therapeutic decision-making. Furthermore, individual characteristics of health care providers, such as interoceptive ability, should be taken into account when constructing models to prevent the breakdown of healthcare systems in cases of severe emergency.

Safety of reducing antibiotic prescribing in primary care: a mixed-methods study

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.

A scientific theory of gist communication and misinformation resistance, with implications for health, education, and policy

A framework is presented for understanding how misinformation shapes decision-making, which has cognitive representations of gist at its core. I discuss how the framework goes beyond prior work, and how it can be implemented so that valid scientific messages are more likely to be effective, remembered, and shared through social media, while misinformation is resisted. The distinction between mental representations of the rote facts of a message-its verbatim representation-and its gist explains several paradoxes, including the frequent disconnect between knowing facts and, yet, making decisions that seem contrary to those facts. Decision makers can falsely remember the gist as seen or heard even when they remember verbatim facts. Indeed, misinformation can be more compelling than information when it provides an interpretation of reality that makes better sense than the facts. Consequently, for many issues, scientific information and misinformation are in a battle for the gist. A fuzzy-processing preference for simple gist explains expectations for antibiotics, the spread of misinformation about vaccination, and responses to messages about global warming, nuclear proliferation, and natural disasters. The gist, which reflects knowledge and experience, induces emotions and brings to mind social values. However, changing mental representations is not sufficient by itself; gist representations must be connected to values. The policy choice is not simply between constraining behavior or persuasion-there is another option. Science communication needs to shift from an emphasis on disseminating rote facts to achieving insight, retaining its integrity but without shying away from emotions and values.

Economic and Behavioral Influencers of Vaccination and Antimicrobial Use

Despite vast improvements in global vaccination coverage during the last decade, there is a growing trend in vaccine hesitancy and/or refusal globally. This has implications for the acceptance and coverage of a potential vaccine against COVID-19. In the United States, the number of children exempt from vaccination for “philosophical belief-based” non-medical reasons increased in 12 of the 18 states that allowed this policy from 2009 to 2017 (1). Meanwhile, the overuse and misuse of antibiotics, especially in young children, have led to increasing rates of drug resistance that threaten our ability to treat infectious diseases. Vaccine hesitancy and antibiotic overuse exist side-by-side in the same population of young children, and it is unclear why one modality (antibiotics) is universally seen as safe and effective, while the other (vaccines) is seen as potentially hazardous by some. In this review, we consider the drivers shaping the use of vaccines and antibiotics in the context of three factors: individual incentives, risk perceptions, and social norms and group dynamics. We illustrate how these factors contribute to the societal and individual costs of vaccine underuse and antimicrobial overuse. Ultimately, we seek to understand these factors that are at the nexus of infectious disease epidemiology and social science to inform policy-making.

To illuminate and motivate: A fuzzy-trace model of the spread of information online

We propose, and test, a model of online media platform users' decisions to act on, and share, received information. Specifically, we focus on how mental representations of message content drive its spread. Our model is based on Fuzzy-Trace Theory (FTT), a leading theory of decision under risk. Per FTT, online content is mentally represented in two ways: verbatim (objective, but decontextualized, facts), and gist (subjective, but meaningful, interpretation). Although encoded in parallel, gist tends to drive behaviors more strongly than verbatim representations for most individuals. Our model uses factors derived from FTT to make predictions regarding which content is more likely to be shared, namely: a) different levels of mental representation, b) the motivational content of a message, c) difficulty of information processing (e.g., the ease with which a given message may be comprehended and, therefore, its gist extracted), and d) social values.

Risks of use and non-use of antibiotics in primary care: qualitative study of prescribers' views

PURPOSE

The emergence of antimicrobial resistance has led to increasing efforts to reduce unnecessary use of antibiotics in primary care, but potential hazards from bacterial infection continue to cause concern. This study investigated how primary care prescribers perceive risk and safety concerns associated with reduced antibiotic prescribing.

METHODS

Qualitative study using semistructured interviews conducted with primary care prescribers from 10 general practices in an urban area and a shire town in England. A thematic analysis was conducted.

RESULTS

Thirty participants were recruited, including twenty-three general practitioners, five nurses and two pharmacists. Three main themes were identified: risk assessment, balancing treatment risks and negotiating decisions and risks. Respondents indicated that their decisions were grounded in clinical risk assessment, but this was informed by different approaches to antibiotic use, with most leaning towards reduced prescribing. Prescribers' perceptions of risk included the consequences of both inappropriate prescribing and inappropriate withholding of antibiotics. Sepsis was viewed as the most concerning potential outcome of non-prescribing, leading to possible patient harm and potential litigation. Risks of antibiotic prescribing included antibiotic resistant and Clostridium difficile infections, as well as side effects, such as rashes, that might lead to possible mislabelling as antibiotic allergy. Prescribers elicited patient preferences for use or avoidance of antibiotics to inform management strategies, which included educational advice, advice on self-management including warning signs, use of delayed prescriptions and safety netting.

CONCLUSIONS

Attitudes towards antibiotic prescribing are evolving, with reduced antibiotic prescribing now being approached more systematically. The safety trade-offs associated with either use or non-use of antibiotics present difficulties especially when prescribing decisions are inconsistent with patients' expectations.

COVID-19: An Emerging Threat to Antibiotic Stewardship in the Emergency Department

While current research efforts focus primarily on identifying patient level interventions that mitigate the direct impact of COVID-19, it is important to consider the collateral effects of COVID-19 on antimicrobial resistance. Early reports suggest high rates of antibiotic utilization in COVID-19 patients despite their lack of direct activity against viral pathogens. The ongoing pandemic is exacerbating known barriers to optimal antibiotic stewardship in the ED, representing an additional direct threat to patient safety and public health. There is an urgent need for research analyzing overall and COVID-19 specific antibiotic prescribing trends in the ED. Optimizing ED stewardship during COVID-19 will likely require a combination of traditional stewardship approaches (e.g. academic detailing, provider education, care pathways) and effective implementation of host response biomarkers and rapid COVID-19 diagnostics. Antibiotic stewardship interventions with demonstrated efficacy in mitigating the impact of COVID-19 on ED prescribing should be widely disseminated and inform the ongoing pandemic response.

The Impact of Influenza Vaccination on Antibiotic Use in the United States, 2010-2017

Background

Influenza, which peaks seasonally, is an important driver for antibiotic prescribing. Although influenza vaccination has been shown to reduce severe illness, evidence of the population-level effects of vaccination coverage on rates of antibiotic prescribing in the United States is lacking.

Methods

We conducted a retrospective analysis of influenza vaccination coverage and antibiotic prescribing rates from 2010 to 2017 across states in the United States, controlling for differences in health infrastructure and yearly vaccine effectiveness. Using data from IQVIA’s Xponent database and the US Centers for Disease Control and Prevention’s FluVaxView, we employed fixed-effects regression analysis to analyze the relationship between influenza vaccine coverage rates and the number of antibiotic prescriptions per 1000 residents from January to March of each year.

Results

We observed that, controlling for socioeconomic differences, access to health care, childcare centers, climate, vaccine effectiveness, and state-level differences, a 10–percentage point increase in the influenza vaccination rate was associated with a 6.5% decrease in antibiotic use, equivalent to 14.2 (95% CI, 6.0–22.4; P = .001) fewer antibiotic prescriptions per 1000 individuals. Increased vaccination coverage reduced prescribing rates the most in the pediatric population (0–18 years), by 15.2 (95% CI, 9.0–21.3; P < .001) or 6.0%, and the elderly (aged 65+), by 12.8 (95% CI, 6.5–19.2; P < .001) or 5.2%.

Conclusions

Increased influenza vaccination uptake at the population level is associated with state-level reductions in antibiotic use. Expanding influenza vaccination could be an important intervention to reduce unnecessary antibiotic prescribing.

Antibiotic Prescribing for Viral Respiratory Infections in the Pediatric Emergency Department and Urgent Care

BACKGROUND

Viral acute respiratory tract infections (vARTI) are a frequent source of inappropriate antibiotic prescribing. We describe the prevalence of antibiotic prescribing for vARTI in the pediatric emergency department (ED) and urgent care (UC) within a health system, and identify factors associated with overall and broad-spectrum antibiotic prescribing.

METHODS

Retrospective chart review within a single pediatric referral health system. Visits of patients, 3 months- 17 years old, with a discharge diagnosis of a vARTI from 2010 to 2015. Data collected included specific vARTI diagnosis, site type (ED or UC), provider type [pediatric emergency medicine subspecialist or physicians, nurse practitioners, physician assistants (non-PEM)] and discharge antibiotics. Odds ratios and 95% confidence intervals (CI) were calculated where appropriate.

RESULTS

There were 132,458 eligible visits, mean age 4.1 ± 4.3 years. Fifty-three percent were treated in an ED. Advanced practice providers, a term encompassing nurse practitioners and physician assistants, were the most common provider type (47.7%); 16.5% of patients were treated by a pediatric emergency medicine subspecialist. Antibiotics were prescribed for 3.8% (95% CI: 3.72-3.92) of children with vARTI; 25.4% (95% CI: 24.2-26.6) of these were broad-spectrum, most commonly first-generation cephalosporins (11%; 95% CI 10.2-11.9). Patients treated in an ED or by a non-PEM and those receiving chest radiograph (CXR) received antibiotics most frequently. Prescribing rates varied by specific vARTI diagnosis.

CONCLUSIONS

Patients discharged from the pediatric ED or UC with vARTI receive inappropriate antibiotics at a lower rate than reported in other community settings; however, they frequently receive broad-spectrum agents.

Antimicrobial stewardship in the outpatient setting: A review and proposed framework

Antimicrobial misuse is still a significant problem, and most inappropriate use occurs in the outpatient setting. In this article, we provide a review of available literature on outpatient antimicrobial stewardship in primary care settings, and we propose a novel implementation framework.

Attitudes of High Versus Low Antibiotic Prescribers in the Management of Upper Respiratory Tract Infections: a Mixed Methods Study

IMPORTANCE

Inappropriate antibiotic use for upper respiratory tract infections (URTIs) is an ongoing problem in primary care. There is extreme variation in the prescribing practices of individual physicians, which cannot be explained by clinical factors.

OBJECTIVE

To identify factors associated with high and low prescriber status for management of URTIs in primary care practice.

DESIGN AND PARTICIPANTS

Exploratory sequential mixed-methods design including interviews with primary care physicians in a large health system followed by a survey. Twenty-nine physicians participated in the qualitative interviews. Interviews were followed by a survey in which 109 physicians participated.

MAIN MEASURES

Qualitative interviews were used to obtain perspectives of high and low prescribers on factors that influenced their decision making in the management of URTIs. A quantitative survey was created based on qualitative interviews and responses compared to actual prescribing rates. An assessment of self-prescribing pattern relative to their peers was also conducted.

RESULTS

Qualitative interviews identified themes such as clinical factors (patient characteristics, symptom duration, and severity), nonclinical factors (physician-patient relationship, concern for patient satisfaction, preference and expectation, time pressure), desire to follow evidence-based medicine, and concern for adverse effects to influence prescribing. In the survey, reported concern regarding antibiotic side effects and the desire to practice evidence-based medicine were associated with lower prescribing rates whereas reported concern for patient satisfaction and patient demand were associated with high prescribing rates. High prescribers were generally unaware of their high prescribing status.

CONCLUSIONS AND RELEVANCE

Physicians report that nonclinical factors frequently influence their decision to prescribe antibiotics for URTI. Physician concerns regarding antibiotic side effects and patient satisfaction are important factors in the decision-making process. Changes in the health system addressing both physicians and patients may be necessary to attain desired prescribing levels.

Biomarker-guided antibiotic stewardship in suspected ventilator-associated pneumonia (VAPrapid2): a randomised controlled trial and process evaluation

BACKGROUND

Ventilator-associated pneumonia is the most common intensive care unit (ICU)-acquired infection, yet accurate diagnosis remains difficult, leading to overuse of antibiotics. Low concentrations of IL-1β and IL-8 in bronchoalveolar lavage fluid have been validated as effective markers for exclusion of ventilator-associated pneumonia. The VAPrapid2 trial aimed to determine whether measurement of bronchoalveolar lavage fluid IL-1β and IL-8 could effectively and safely improve antibiotic stewardship in patients with clinically suspected ventilator-associated pneumonia.

METHODS

VAPrapid2 was a multicentre, randomised controlled trial in patients admitted to 24 ICUs from 17 National Health Service hospital trusts across England, Scotland, and Northern Ireland. Patients were screened for eligibility and included if they were 18 years or older, intubated and mechanically ventilated for at least 48 h, and had suspected ventilator-associated pneumonia. Patients were randomly assigned (1:1) to biomarker-guided recommendation on antibiotics (intervention group) or routine use of antibiotics (control group) using a web-based randomisation service hosted by Newcastle Clinical Trials Unit. Patients were randomised using randomly permuted blocks of size four and six and stratified by site, with allocation concealment. Clinicians were masked to patient assignment for an initial period until biomarker results were reported. Bronchoalveolar lavage was done in all patients, with concentrations of IL-1β and IL-8 rapidly determined in bronchoalveolar lavage fluid from patients randomised to the biomarker-based antibiotic recommendation group. If concentrations were below a previously validated cutoff, clinicians were advised that ventilator-associated pneumonia was unlikely and to consider discontinuing antibiotics. Patients in the routine use of antibiotics group received antibiotics according to usual practice at sites. Microbiology was done on bronchoalveolar lavage fluid from all patients and ventilator-associated pneumonia was confirmed by at least 104 colony forming units per mL of bronchoalveolar lavage fluid. The primary outcome was the distribution of antibiotic-free days in the 7 days following bronchoalveolar lavage. Data were analysed on an intention-to-treat basis, with an additional per-protocol analysis that excluded patients randomly assigned to the intervention group who defaulted to routine use of antibiotics because of failure to return an adequate biomarker result. An embedded process evaluation assessed factors influencing trial adoption, recruitment, and decision making. This study is registered with ISRCTN, ISRCTN65937227, and ClinicalTrials.gov, NCT01972425.

FINDINGS

Between Nov 6, 2013, and Sept 13, 2016, 360 patients were screened for inclusion in the study. 146 patients were ineligible, leaving 214 who were recruited to the study. Four patients were excluded before randomisation, meaning that 210 patients were randomly assigned to biomarker-guided recommendation on antibiotics (n=104) or routine use of antibiotics (n=106). One patient in the biomarker-guided recommendation group was withdrawn by the clinical team before bronchoscopy and so was excluded from the intention-to-treat analysis. We found no significant difference in the primary outcome of the distribution of antibiotic-free days in the 7 days following bronchoalveolar lavage in the intention-to-treat analysis (p=0·58). Bronchoalveolar lavage was associated with a small and transient increase in oxygen requirements. Established prescribing practices, reluctance for bronchoalveolar lavage, and dependence on a chain of trial-related procedures emerged as factors that impaired trial processes.

INTERPRETATION

Antibiotic use remains high in patients with suspected ventilator-associated pneumonia. Antibiotic stewardship was not improved by a rapid, highly sensitive rule-out test. Prescribing culture, rather than poor test performance, might explain this absence of effect.

FUNDING

UK Department of Health and the Wellcome Trust.

Antimicrobial stewardship programs; a two-part narrative review of step-wise design and issues of controversy Part I: step-wise design of an antimicrobial stewardship program

Regardless of one's opinion of antimicrobial stewardship programs (ASPs), it is hardly possible to work in hospital care and not be exposed to the term or its practical effects. Despite the term being relatively new, the number of publications in the field is vast, including several excellent reviews of general and specific aspects. Work in antimicrobial stewardship is complex, and includes not only aspects of infectious disease and microbiology, but also of epidemiology, genetics, behavioural psychology, systems science, economics and ethics, to name a few. This review aims to take several of these aspects and the scientific evidence of antimicrobial stewardship studies and merge them into two questions: How should we design ASPs based on what we know today? And which are the most essential unanswered questions regarding antimicrobial stewardship on a broader scale? This narrative review is written in two separate parts aiming to provide answers to the two questions. This first part is written as a step-wise approach to designing a stewardship intervention based on the pillars of unmet need, feasibility, scientific evidence and necessary core elements. It is written mainly as a guide to someone new to the field. It is sorted into five distinct steps: (a) focusing on designing aims; (b) assessing performance and local barriers to rational antimicrobial use; (c) deciding on intervention technique; (d) practical, tailored design including core element inclusion; and (e) evaluation and sustainability. The second part, published separately, formulates ten critical questions on controversies in the field of antimicrobial stewardship. It is aimed at clinicians and researchers with stewardship experience and strives to promote discussion, not to provide answers.

Antimicrobial stewardship programs; a two-part narrative review of step-wise design and issues of controversy. Part II: Ten questions reflecting knowledge gaps and issues of controversy in the field of antimicrobial stewardship

Regardless of one's opinion on antimicrobial stewardship programs (ASPs), it is hardly possible to work in hospital care and not be exposed to the term or its practical effects. Despite the term being relatively new, the number of publications in the field is vast, including several excellent reviews of general and specific aspects. Work in antimicrobial stewardship is complex, and include aspects not only of infectious disease and microbiology, but also of epidemiology, genetics, behavioural psychology, systems science, economics and ethics, to name but a few. This review aims to take several of these aspects and the scientific evidence from antimicrobial stewardship studies and merge them into two questions: How should we design ASPs based on what we know today? and Which are the most essential unanswered questions regarding antimicrobial stewardship on a broader scale? This narrative review is written in two separate parts aiming to provide answers to the two questions. The first part, published separately, is written as a step-wise approach to designing a stewardship intervention based on the pillars of unmet need, feasibility, scientific evidence and necessary core elements. It is written mainly as a guide to someone new to the field. It is sorted into five distinct steps; (a) focusing on designing aims; (b) assessing performance and local barriers to rational antimicrobial use; (c) deciding on intervention technique; (d) practical, tailored design including core element inclusion; and (e) evaluation and sustainability. This second part formulates 10 critical questions on controversies in the field of antimicrobial stewardship. It is aimed at clinicians and researchers with stewardship experience and strives to promote discussion, not to provide answers.

General practitioners' accounts of negotiating antibiotic prescribing decisions with patients: a qualitative study on what influences antibiotic prescribing in low, medium and high prescribing practices

BACKGROUND

Antimicrobial resistance (AMR) is high on the UK public health policy agenda, and poses challenges to patient safety and the provision of health services. Widespread prescribing of antibiotics is thought to increase AMR, and mostly takes place in primary medical care. However, prescribing rates vary substantially between general practices. The aim of this study was to understand contextual factors related to general practitioners' (GPs) antibiotic prescribing behaviour in low, high, and around the mean (medium) prescribing primary care practices.

METHODS

Qualitative semi-structured interviews were conducted with 41 GPs working in North-West England. Participants were purposively sampled from practices with low, medium, and high antibiotic prescribing rates adjusted for the number and characteristics of patients registered in a practice. The interviews were analysed thematically.

RESULTS

This study found that optimizing antibiotic prescribing creates tensions for GPs, particularly in doctor-patient communication during a consultation. GPs balanced patient expectations and their own decision-making in their communication. When not prescribing antibiotics, GPs reported the need for supportive mechanisms, such as regular practice meetings, within the practice, and in the wider healthcare system (e.g. longer consultation times). In low prescribing practices, GPs reported that increasing dialogue with colleagues, having consistent patterns of prescribing within the practice, supportive practice policies, and enough resources such as consultation time were important supports when not prescribing antibiotics.

CONCLUSIONS

Insight into GPs' negotiations with patient and public health demands, and consistent and supportive practice-level policies can help support prudent antibiotic prescribing among primary care practices.

Patients' and Clinicians' Perceptions of Antibiotic Prescribing for Upper Respiratory Infections in the Acute Care Setting

Reducing inappropriate prescribing is key to mitigating antibiotic resistance, particularly in acute care settings. Clinicians' prescribing decisions are influenced by their judgments and actual or perceived patient expectations. Fuzzy trace theory predicts that patients and clinicians base such decisions on categorical gist representations that reflect the bottom-line understanding of information about antibiotics. However, due to clinicians' specialized training, the categorical gists driving clinicians' and patients' decisions might differ, which could result in mismatched expectations and inefficiencies in targeting interventions. We surveyed clinicians and patients from 2 large urban academic hospital emergency departments (EDs) and a sample of nonpatient subjects regarding their gist representations of antibiotic decisions, as well as relevant knowledge and expectations. Results were analyzed using exploratory factor analysis (EFA) and multifactor regression. In total, 149 clinicians (47% female; 74% white), 519 online subjects (45% female; 78% white), and 225 ED patients (61% female; 56% black) completed the survey. While clinicians demonstrated greater knowledge of antibiotics and concern about side effects than patients, the predominant categorical gist for both patients and clinicians was "why not take a risk," which compares the status quo of remaining sick to the possibility of benefit from antibiotics. This gist also predicted expectations and prior prescribing in the nonpatient sample. Other representations reflected the gist that "germs are germs" conflating bacteria and viruses, as well as perceptions of side effects and efficacy. Although individually rational, reliance on the "why not take a risk" representation can lead to socially suboptimal results, including antibiotic resistance and individual patient harm due to adverse events. Changing this representation could alter clinicians' and patients' expectations, suggesting opportunities to reduce overprescribing.

The successful uptake and sustainability of rapid infectious disease and antimicrobial resistance point-of-care testing requires a complex 'mix-and-match' implementation package

The emergence and spread of antimicrobial resistance is one of the major global issues currently threatening the health and wealth of nations, with effective guidelines and intervention strategies urgently required. Such guidelines and interventions should ideally be targeted at individuals, communities, and nations, requiring international coordination for maximum effect. In this respect, the European Joint Programming Initiative on Antimicrobial Resistance Transnational Working Group 'Antimicrobial Resistance - Rapid Diagnostic Tests' (JPIAMR AMR-RDT) is proposing to consider a 'mix-and-match' package for the implementation of point-of-care testing (PoCT), which is described in this publication. The working group was established with the remit of identifying barriers and solutions to the development and implementation of rapid infectious disease PoCT for combatting the global spread of antimicrobial resistance. It constitutes a multi-sectoral collaboration between medical, technological, and industrial opinion leaders involved in in vitro diagnostics development, medical microbiology, and clinical infectious diseases. The mix-and-match implementation package is designed to encourage the implementation of rapid infectious disease and antimicrobial resistance PoCT in transnational medical environments for use in the fight against increasing antimicrobial resistance.

Procalcitonin-Guided Antibiotic Therapy Reduces Antibiotic Use for Lower Respiratory Tract Infections in a United States Medical Center: Results of a Clinical Trial

Background

European trials using procalcitonin (PCT)-guided antibiotic therapy for patients with lower respiratory tract infections (LRTIs) have demonstrated significant reductions in antibiotic use without increasing adverse outcomes. Few studies have examined PCT for LRTIs in the United States.

Methods

In this study, we evaluated whether a PCT algorithm would reduce antibiotic exposure in patients with LRTI in a US hospital. We conducted a controlled pre-post trial comparing an intervention group of PCT-guided antibiotic therapy to a control group of usual care. Consecutive patients admitted to medicine services and receiving antibiotics for LRTI were enrolled in the intervention. Providers were encouraged to discontinue antibiotics according to a PCT algorithm. Control patients were similar patients admitted before the intervention.

Results

The primary endpoint was median antibiotic duration. Overall adverse outcomes at 30 days comprised death, transfer to an intensive care unit, antibiotic side effects, Clostridium difficile infection, disease-specific complications, and post-discharge antibiotic prescription for LRTI. One hundred seventy-four intervention patients and 200 controls were enrolled. Providers complied with the PCT algorithm in 75% of encounters. Procalcitonin-guided therapy reduced median antibiotic duration for pneumonia from 7 days to 6 (P = .045) and acute exacerbation of chronic obstructive pulmonary disease (AECOPD) from 4 days to 3 (P = .01). There was no difference in the rate of adverse outcomes in the PCT and control groups.

Conclusions

A PCT-guided algorithm safely reduced the duration of antibiotics for treating LRTI. Utilization of a PCT algorithm may aid antibiotic stewardship efforts.

This clinical trial was a single-center, controlled, pre-post study of PCT-guided antibiotic therapy for LRTI. The intervention (incorporation of PCT-guided algorithms) started on April 1, 2017: the preintervention (control group) comprised patients admitted from November 1, 2016 to April 16, 2017, and the postintervention group comprised patients admitted from April 17, 2017 to November 29, 2017 (Supplementary Figure 1). The study comprised patients admitted to the internal medicine services to a medical ward, the Medical Intensive Care Unit (MICU), the Cardiac Intensive Care Unit (CICU), or the Progressive Care Unit (PCU) “step down unit”. The registration data for the trails are in the ClinicalTrials.gov database, number NCT0310910.

Antimicrobial Stewardship in the Emergency Department

The emergency department (ED) is the hub of the US health care system. Acute infectious diseases are frequently encountered in the ED setting, making this a critical setting for antimicrobial stewardship efforts. Systems level and behavioral stewardship interventions have demonstrated success in the ED setting but successful implementation depends on institutional support and the presence of a physician champion. Antimicrobial stewardship efforts in the ED should target high-impact areas: antibiotic prescribing for nonindicated respiratory tract conditions, such as bronchitis and sinusitis; overtreatment of asymptomatic bacteriuria; and using two antibiotics (double coverage) for uncomplicated cases of cellulitis or abscess.

National Estimates of Emergency Department Visits for Antibiotic Adverse Events Among Adults-United States, 2011-2015

BACKGROUND

Detailed, nationally representative data describing high-risk populations and circumstances involved in antibiotic adverse events (AEs) can inform approaches to prevention.

OBJECTIVE

Describe US burden, rates, and characteristics of emergency department (ED) visits by adults for antibiotic AEs.

DESIGN

Nationally representative, public health surveillance of adverse drug events (National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance [NEISS-CADES]) and a nationally projected database of dispensed prescriptions (QuintilesIMS), 2011-2015.

PATIENTS

Antibiotic-treated adults (≥ 20 years) seeking ED care.

MAIN MEASURES

Estimated annual numbers and rates of ED visits for antibiotic AEs among outpatients treated with systemically administered antibiotics.

KEY RESULTS

Based on 10,225 cases, US adults aged ≥ 20 years made an estimated 145,490 (95% confidence interval, 115,279-175,701) ED visits for antibiotic AEs each year in 2011-2015. Antibiotics were implicated in 13.7% (12.3-15.2%) of all estimated adult ED visits for adverse drug events. Most (56.6%; 54.8-58.4%) antibiotic AE visits involved adults aged < 50 years, and 71.8% (70.4-73.1%) involved females. Accounting for prescriptions dispensed from retail and long-term care pharmacies, adults aged 20-34 years had twice the estimated rate of ED visits for oral antibiotic AEs compared with those aged ≥ 65 years (9.7 [7.6-11.8] versus 4.6 [3.6-5.7] visits per 10,000 dispensed prescriptions, respectively). Allergic reactions accounted for three quarters (74.3%; 70.0-78.6%) of estimated ED visits for antibiotic AEs. The three most frequently implicated antibiotic classes in ED visits for antibiotic AEs were oral sulfonamides (23.2%; 20.6-25.8%), penicillins (20.8%; 19.3-22.4%), and quinolones (15.7%; 14.2-17.1%). Per-prescription rates declined with increasing age group.

CONCLUSIONS

Antibiotics are a common cause of ED visits by adults for adverse drug events and represent an important safety issue. Quantifying risks of AEs from specific antibiotics for specific patient populations, such as younger adults, provides additional information to help clinicians assess risks versus benefits when making the decision to prescribe or not prescribe an antibiotic. AE rates may also facilitate communication with patients about antibiotic risks.

When Irrational Biases Are Smart: A Fuzzy-Trace Theory of Complex Decision Making

I take a decision-making approach to consider ways of addressing the "unresolved and dramatic problems in the world". Traditional approaches to good decision-making are reviewed. These approaches reduce complex decisions to tradeoffs between magnitudes of probabilities, and outcomes in which the quantity and precision of information are key to making good decisions. I discuss a contrasting framework, called "fuzzy-trace theory", which emphasizes understanding the simple gist of options and applying core social and moral values. Importantly, the tendency to rely on meaningful but simple gist increases from childhood to adulthood (or, in adulthood, as people gain experience in a domain), so that specific irrational biases grow with knowledge and experience. As predicted theoretically, these violations of rationality in the traditional sense are associated empirically with healthier and more adaptive outcomes. Thus, interventions that help decision makers understand the essential gist of their options and how it connects to core values are practical approaches to reducing "unresolved and dramatic problems in the world" one decision at a time.

Outpatient Antibiotic Use and the Need for Increased Antibiotic Stewardship Efforts

Antibiotic-resistant infections pose a growing threat to public health. Antibiotic use, regardless of whether it is warranted, is a primary factor in the development of resistance. In the United States, the majority of antibiotic health care expenditures are due to prescribing in outpatient settings. Much of this prescribing is inappropriate, with research showing that at least 30% of antibiotic use in outpatient settings is unnecessary. In this State of the Art Review article, we provide an overview of the latest research on outpatient antibiotic prescribing practices in the United States. Although many of the researchers in these studies describe antibiotic prescribing across all patient age groups, we highlight prescribing in pediatric populations when data are available. We then describe the various factors that can influence a physician's prescribing decisions and drive inappropriate antibiotic use and the potential role of behavioral science in enhancing stewardship interventions to address these drivers. Finally, we highlight the role that a wide range of health care stakeholders can play in aiding the expansion of outpatient stewardship efforts that are needed to fully address the threat of antibiotic resistance.