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Tigges P, Greser A, Gágyor I, Kraft J, Maun A, Schmiemann G, Schwienhorst-Stich EM, Heintze C, Schuster A. Addressing AMR and planetary health in primary care: the potential of general practitioners as change agents. Front Public Health 2024; 12:1383423. [PMID: 39145182 PMCID: PMC11322125 DOI: 10.3389/fpubh.2024.1383423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 07/11/2024] [Indexed: 08/16/2024] Open
Abstract
Introduction Antimicrobial resistance is closely linked with the health and stability of environmental systems and therefore a challenge for the health of the planet. General Practitioners, owing to their trusted positions and close patient relationships, can play a crucial role in addressing antimicrobial resistance within the framework of Planetary Health. The goal of our study was to examine General Practitioners' knowledge, attitude, and practice regarding the linkage of antimicrobial resistance with Planetary Health to understand their potential as agents of change in this domain. Materials and methods We conducted 19 guided interviews with General Practitioners from four different German federal states (August-September 2022). Participants were selected from the intervention group of the RedAres randomized controlled trial, a study designed to optimize therapy and prescribing practices for uncomplicated urinary tract infections in general practice. Data were analyzed using Mayring's structured qualitative content analysis and the typology approach by Kelle and Kluge. Results General Practitioners generally demonstrated the ability to identify the interlinkages between antimicrobial resistance and Planetary Health. However, they exhibited varying levels of knowledge, problem awareness, and accountability for the associated challenges and partially outsourced the responsibility for Planetary Health. Some General Practitioners were capable of integrating Planetary Health arguments into patient counseling. They recognized rational prescribing practice, self-reflection on antimicrobial resistance and Planetary Health, interprofessional exchange, and raising awareness among patients as potential avenues for engagement in promoting Planetary Health. Discussion As antimicrobial resistance is increasingly recognized as a Planetary Health challenge, empowering General Practitioners as change agents requires tailored measures based on their level of previous knowledge and their attitude toward Planetary Health. General Practitioners express a need for concrete advice on how to integrate antimicrobial resistance as a Planetary Health topic into their daily activities. Developing and evaluating adaptable training materials is essential. Additionally, the integration of Planetary Health outcomes into clinical guidelines could accelerate the adoption of this dimension in antibiotic prescribing practices within primary care settings.
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Affiliation(s)
- Paula Tigges
- Charité – Universitätsmedizin Berlin, Institute of General Practice, Berlin, Germany
| | - Alexandra Greser
- Department of General Practice, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Ildikó Gágyor
- Department of General Practice, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Judith Kraft
- Charité – Universitätsmedizin Berlin, Institute of Biometry and Clinical Epidemiology, Berlin, Germany
| | - Andy Maun
- Institute of General Practice/Primary Care, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Guido Schmiemann
- Department of Health Service Research, Institute for Public Health and Nursing Research, University of Bremen, Bremen, Germany
| | - Eva-Maria Schwienhorst-Stich
- Department of General Practice, University Hospital Wuerzburg, Wuerzburg, Germany
- Faculty of Medicine, Working Group Climate and Planetary Health, University of Würzburg, Wuerzburg, Germany
| | - Christoph Heintze
- Charité – Universitätsmedizin Berlin, Institute of General Practice, Berlin, Germany
| | - Angela Schuster
- Charité – Universitätsmedizin Berlin, Institute of General Practice, Berlin, Germany
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Lansink C, Sinha B, Meessen N, Dekkers T, Beerlage-de Jong N. Why Do Physicians Prescribe Antibiotics? A Systematic Review of the Psycho-Socio-Organisational Factors Related to Potentially Inappropriate Prescribing of Antimicrobials in Europe. Infect Dis Rep 2024; 16:664-683. [PMID: 39195002 DOI: 10.3390/idr16040051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2024] [Revised: 07/20/2024] [Accepted: 07/22/2024] [Indexed: 08/29/2024] Open
Abstract
Purpose: Effective antimicrobial use enhances care quality and combats antibiotic resistance. Yet, non-guideline factors influence potentially inappropriate prescribing. This study explores psycho-socio-organisational factors in antimicrobial prescribing as perceived by physicians across primary, secondary, and tertiary care. Methods: Adhering to PRISMA guidelines, a systematic review was conducted using PubMed and Scopus databases from 1 January 2000, to 8 March 2023, with an update search until 30 January 2024. Inclusion criteria focused on studies in Europe exploring psycho-socio-organisational factors for antibiotic prescribing from physicians' perspectives in hospital, inpatient, or primary care settings. Exclusion criteria targeted out-of-office prescriptions or low-quality studies. To evaluate the latter, several quality and risk-of-bias checklists were used. Data were extracted on study characteristics, study design, and methods and identified determinants of antibiotic prescribing. Data was analysed using a narrative synthesis method. Results: Among 8370 articles, 58 met inclusion criteria, yielding 35 articles from 23 countries. Three main themes emerged: personal, psychological, and organisational factors, encompassing seven determinants including work experience, knowledge, guideline adherence, uncertainty management, perceived pressure, time constraints, and diagnostic resource availability. Uncertainty management was key, with work experience and knowledge mitigating it. No additional factors emerged in the updated search. Conclusion: Enhanced uncertainty management decreases perceived patient and/or parental pressure to prescribe antibiotics, contributing to reducing potentially inappropriate prescribing (PIP). Therefore, it is imperative to educate physicians on effectively managing uncertainty. Interventions to improve antibiotic prescribing should be tailored to the specific needs and preferences of the different prescribing physicians.
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Affiliation(s)
- Chiara Lansink
- Section of Health Technology and Services Research, Technical Medical Centre, University of Twente, 7522 NB Enschede, The Netherlands
| | - Bhanu Sinha
- University of Groningen, University Medical Center Groningen, Department of Medical Microbiology and Infection Prevention, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Nico Meessen
- University of Groningen, University Medical Center Groningen, Department of Medical Microbiology and Infection Prevention, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Tessa Dekkers
- Section of Psychology, Health and Technology, Centre for eHealth and Wellbeing Research, University of Twente, 7500 AE Enschede, The Netherlands
| | - Nienke Beerlage-de Jong
- Section of Health Technology and Services Research, Technical Medical Centre, University of Twente, 7522 NB Enschede, The Netherlands
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Kuitunen I, Renko M. The Effect of Rapid Point-of-Care Respiratory Pathogen Testing on Antibiotic Prescriptions in Acute Infections-A Systematic Review and Meta-analysis of Randomized Controlled Trials. Open Forum Infect Dis 2023; 10:ofad443. [PMID: 37662450 PMCID: PMC10472488 DOI: 10.1093/ofid/ofad443] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 08/16/2023] [Indexed: 09/05/2023] Open
Abstract
Background Rapid point-of-care testing for respiratory pathogens has gained increasing popularity, but its impact on antibiotic consumption is unclear. Thus, the aim of this systematic review and meta-analysis was to estimate the effect of rapid point-of-care testing on antibiotic prescriptions. Methods The search for this systematic review with meta-analysis was performed in February 2023. Randomized controlled trials investigating the impact of testing for respiratory pathogens in all-aged patients were included regardless of the comparator. The main outcome was the antibiotic prescription rate. Analyses were stratified by test type, test setting, and patient age. A random-effects Mantel-Haenszel model was used to calculate risk ratios with 95% confidence intervals. Risk of bias was assessed for included studies, and the quality of the evidence was rated according to GRADE. Results A total of 754 abstracts were screened, and 10 studies were included in the analysis. Risk of bias was high in 2, low in 4, and had some concerns in 4 studies. Four studies analyzed influenza and respiratory syncytial virus tests, and 6 studies analyzed multiplex (viral and/or bacterial) testing. The prescription rate was 48.2% (496/1029) in the influenza and respiratory syncytial virus test group and 48.7% (540/1109) in the control group (risk ratio [RR], 0.97; 95% CI, 0.92-1.02; moderate-quality evidence). The prescription rate in the multiplex testing group was 54.3% (1554/2859), and it was 57.3% (1336/2326) in the control group (RR, 1.00; 95% CI, 0.96-1.04; moderate-quality evidence). In an age-stratified analysis, the prescription rates showed no evidence of a difference (children: RR, 1.03; 95% CI, 0.81-1.30; adults: RR, 0.98; 95% CI, 0.96-1.01; very low- and moderate-quality evidence). Conclusions We found moderate-quality evidence that rapid point-of-care testing for respiratory pathogens does not decrease the antibiotic prescription rate.
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Affiliation(s)
- Ilari Kuitunen
- Department of Pediatrics, University of Eastern Finland, Institute of Clinical Medicine, Kuopio, Finland
- Department of Pediatrics, Kuopio University Hospital, Kuopio, Finland
| | - Marjo Renko
- Department of Pediatrics, University of Eastern Finland, Institute of Clinical Medicine, Kuopio, Finland
- Department of Pediatrics, Kuopio University Hospital, Kuopio, Finland
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Neugebauer M, Ebert M, Vogelmann R. A clinical decision support system improves antibiotic therapy for upper urinary tract infection in a randomized single-blinded study. BMC Health Serv Res 2020; 20:185. [PMID: 32143630 PMCID: PMC7059328 DOI: 10.1186/s12913-020-5045-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Accepted: 02/26/2020] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Due to increasing bacterial resistance rates choosing a correct empiric antibiotic therapy is getting more and more complex. Often medical doctors use information tools to make the right treatment choice. METHODS One hundred sixty six participants (77 medical doctors and 89 medical students) were asked to provide a diagnosis and antibiotic therapy in a simple fictive paper case of upper urinary tract infection (UTI) in a randomized single-blinded study. Participants were randomized to one of four information tools they were allowed to use in the study or control: 1. free internet access, 2. pharmaceutical pocket guide, 3. pocket guide antibiotic therapy, 4. clinical decision support system (CDSS), and control (no information tool). The CDSS was designed for the study. The adherence to the national German UTI guideline was evaluated. RESULTS Only 27.1% (n = 45/166) provided a correct diagnosis of upper UTI and 19.4% (n = 32/166) an antibiotic treatment recommended by national German treatment guidelines indicating their need for information tools. This result was not significantly different between medical doctors and medical students, residents and medical specialists or level of working experience. Using CDSS improved results significantly compared to conventional tools (diagnosis 57.1%; treatment recommendation 40.5%; p < 0,01). Processing time was not different between the use of CDSS and conventional information tools. CDSS users based their decision making on their assigned information tool more than users of conventional tools (73.8% vs. 48.0%; p < 0.01). Using CDSS improved the confidence of participants in their recommendation significantly compared to conventional tools (p < 0.01). CONCLUSIONS Our study suggests that medical professionals require information tools in diagnosing and treating a simple case of upper UTI correctly. CDSS appears to be superior to conventional tools as an information source.
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Affiliation(s)
- M Neugebauer
- Second Department of Internal Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, D-68167, Mannheim, Germany
| | - M Ebert
- Second Department of Internal Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, D-68167, Mannheim, Germany
| | - R Vogelmann
- Second Department of Internal Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, D-68167, Mannheim, Germany.
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5
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Fenta T, Engidawork E, Amogne W, Berha AB. Evaluation of current practice of antimicrobial use and clinical outcome of patients with pneumonia at a tertiary care hospital in Ethiopia: A prospective observational study. PLoS One 2020; 15:e0227736. [PMID: 31999752 PMCID: PMC6992215 DOI: 10.1371/journal.pone.0227736] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 12/29/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Antimicrobial resistance, which is commonly observed in the management of pneumonia, is a major threat to public health and is driven by inappropriate antimicrobial use. The aim of this study was therefore to assess the current practice of antimicrobial utilization and clinical outcomes in the management of adult pneumonia at Tikur Anbessa Specialized Hospital. METHOD A prospective observational study was conducted in the internal medicine wards of Tikur Anbessa Specialized Hospital. The study was conducted from 1 September 2016 to 30 June 2017 and patients aged ≥ 14 years and diagnosed with pneumonia were included. Chart review and self-administered questionnaire were used to collect data regarding pneumonia diagnosis and management as well as clinical outcomes (stable, complications, and in-hospital mortality). Descriptive statistics and binary logistic regressions were performed for data analyses. RESULTS Out of 200 enrolled patients, clinical diagnosis was supported by microbiologic testing and imaging in 75 (37.5%) and 122 (61.0%) cases, respectively. The treatment approach in almost all patients (99.5%) was empirical and no de-escalation therapy was made even after acquiring culture results. The total duration of antimicrobial therapy was 12.05±5.09 days and vancomycin was the most commonly prescribed antimicrobial agent (25%), with 70% of the patients receiving this drug empirically. Nearly, 30% of the patients missed their antimicrobial doses during the course of treatment and stock-out (36.7%) was the major reason. Close to 113 (66%) of the treating physicians used reference books to prescribe antimicrobial agents. Patients' outcomes were found to be stable (66%), in-hospital mortality (18.5%), and ending up in complications (17%). Poor clinical outcome (death and complicated cases) was found to be associated with recent antimicrobial use history (p = 0.007, AOR 2.86(1.33-6.13)), cancer (p = 0.023, AOR 3.46(1.18-10.13)), recent recurrent upper respiratory tract infection (p = 0.046, AOR 3.70(1.02-13.40)), respiratory rate >24 breaths/min or <12 breaths/min (p = 0.013, AOR 2.45(1.21-4.95)) and high level of serum creatinine after initiation of antimicrobial therapy (>1.4mg/dl) (p = 0.032, AOR 2.37(1.07-5.20)). CONCLUSION Antimicrobials are empirically prescribed without sufficient evidence of indication and microbiological or radiological findings. The practice also is not based on local guidelines and no multidisciplinary approach is apparent. [How about: "It is likely that these factors contributed to higher rates of mortality (18.5%) when compared with similar studies in other countries" instead of this "As a result, there were higher rates of mortality (18.5%) when compared with other similar studies"]. Hence, the hospital requires a coordinated intervention to improve rational use of antimicrobials and clinical outcomes through establishing an antimicrobial stewardship program.
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Affiliation(s)
- Theodros Fenta
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Ephrem Engidawork
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Wondwossen Amogne
- Department of Infectious Diseases, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Alemseged Beyene Berha
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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Resman F. Antimicrobial stewardship programs; a two-part narrative review of step-wise design and issues of controversy Part I: step-wise design of an antimicrobial stewardship program. Ther Adv Infect Dis 2020; 7:2049936120933187. [PMID: 32612826 PMCID: PMC7307277 DOI: 10.1177/2049936120933187] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 05/11/2020] [Indexed: 12/27/2022] Open
Abstract
Regardless of one's opinion of antimicrobial stewardship programs (ASPs), it is hardly possible to work in hospital care and not be exposed to the term or its practical effects. Despite the term being relatively new, the number of publications in the field is vast, including several excellent reviews of general and specific aspects. Work in antimicrobial stewardship is complex, and includes not only aspects of infectious disease and microbiology, but also of epidemiology, genetics, behavioural psychology, systems science, economics and ethics, to name a few. This review aims to take several of these aspects and the scientific evidence of antimicrobial stewardship studies and merge them into two questions: How should we design ASPs based on what we know today? And which are the most essential unanswered questions regarding antimicrobial stewardship on a broader scale? This narrative review is written in two separate parts aiming to provide answers to the two questions. This first part is written as a step-wise approach to designing a stewardship intervention based on the pillars of unmet need, feasibility, scientific evidence and necessary core elements. It is written mainly as a guide to someone new to the field. It is sorted into five distinct steps: (a) focusing on designing aims; (b) assessing performance and local barriers to rational antimicrobial use; (c) deciding on intervention technique; (d) practical, tailored design including core element inclusion; and (e) evaluation and sustainability. The second part, published separately, formulates ten critical questions on controversies in the field of antimicrobial stewardship. It is aimed at clinicians and researchers with stewardship experience and strives to promote discussion, not to provide answers.
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Affiliation(s)
- Fredrik Resman
- Department of Translational Medicine, Clinical
Infection Medicine, Lund University, Rut Lundskogs Gata 3, Plan 6, Malmö, 20502,
Sweden
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7
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Schneider S, Salm F, Vincze S, Moeser A, Petruschke I, Schmücker K, Ludwig N, Hanke R, Schröder C, Gropmann A, Behnke M, Lübke-Becker A, Wieler LH, Hagel S, Pletz MW, Gensichen J, Gastmeier P. Perceptions and attitudes regarding antibiotic resistance in Germany: a cross-sectoral survey amongst physicians, veterinarians, farmers and the general public. J Antimicrob Chemother 2019; 73:1984-1988. [PMID: 29590400 DOI: 10.1093/jac/dky100] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 03/02/2018] [Indexed: 11/14/2022] Open
Abstract
Background Drivers of antibiotic (AB) resistance (ABR) include outpatient treatment, hospital care and animal husbandry. During the first phase of the One Health project RAI (Responsible Antibiotic Use via Information and Communication) surveys were conducted in these sectors. Objectives To compare perceptions and attitudes towards ABR among general practitioners (GPs), hospital physicians, veterinarians, pig farmers and the general public. Methods Cross-sectional questions on AB use and ABR were integrated in group-specific surveys of GPs, hospital physicians, veterinarians, pig farmers and the German general population. Results A total of 1789 participants (340 GPs, 170 hospital physicians, 215 pig farmers, 60 veterinarians and 1004 members of the public) responded. Each group tended to identify drivers of ABR as being from outside its own area of activity. Guidelines were shown to be an important information source for AB therapy for all prescriber groups, but the frequency of routine use differed (39% of GPs, 65% of hospital physicians and 53% of veterinarians). Regarding further information sources, hospital physicians preferred smartphone apps and e-learning, GPs preferred non-sponsored training and veterinarians preferred multidisciplinary networks and e-learning. Farmers were predominantly satisfied with existing solutions. Farmers had three times better basic knowledge of ABR and knew twice as many people with MDR organism problems than the general public. They also received information on ABR more often from their veterinarians than patients did from their doctors. Conclusions This study reveals considerable differences in perceptions and attitudes to ABR among the groups investigated. The results can help to tailor future interventions. Furthermore, they promote mutual understanding and thus support the One Health approach.
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Affiliation(s)
- Sandra Schneider
- Institute of Hygiene and Environmental Medicine, Charité University Medical Center Berlin, Hindenburgdamm 27, D-12203 Berlin, Germany
| | - Florian Salm
- Institute of Hygiene and Environmental Medicine, Charité University Medical Center Berlin, Hindenburgdamm 27, D-12203 Berlin, Germany
| | - Szilvia Vincze
- Institute of Microbiology and Epizootics, Department of Veterinary Medicine at the Freie Universität Berlin, Robert-von-Ostertag-Str. 7-13, D-14163 Berlin, Germany
| | - Anne Moeser
- Center for Infectious Diseases and Infection Control, Jena University Hospital, Am Klinikum 1, D-07747 Jena, Germany
| | - Inga Petruschke
- Institute of General Practice and Family Medicine, Jena University Hospital, Bachstrasse 18, D-07743 Jena, Germany
| | - Katja Schmücker
- Institute of General Practice and Family Medicine, Jena University Hospital, Bachstrasse 18, D-07743 Jena, Germany
| | - Norman Ludwig
- Lindgrün GmbH, Cuxhavener Strasse 12, D-10555 Berlin, Germany
| | - Regina Hanke
- Institute of Hygiene and Environmental Medicine, Charité University Medical Center Berlin, Hindenburgdamm 27, D-12203 Berlin, Germany.,Lindgrün GmbH, Cuxhavener Strasse 12, D-10555 Berlin, Germany
| | - Christin Schröder
- Institute of Hygiene and Environmental Medicine, Charité University Medical Center Berlin, Hindenburgdamm 27, D-12203 Berlin, Germany
| | - Alexander Gropmann
- Institute of Hygiene and Environmental Medicine, Charité University Medical Center Berlin, Hindenburgdamm 27, D-12203 Berlin, Germany
| | - Michael Behnke
- Institute of Hygiene and Environmental Medicine, Charité University Medical Center Berlin, Hindenburgdamm 27, D-12203 Berlin, Germany
| | - Antina Lübke-Becker
- Institute of Microbiology and Epizootics, Department of Veterinary Medicine at the Freie Universität Berlin, Robert-von-Ostertag-Str. 7-13, D-14163 Berlin, Germany
| | - Lothar H Wieler
- Institute of Microbiology and Epizootics, Department of Veterinary Medicine at the Freie Universität Berlin, Robert-von-Ostertag-Str. 7-13, D-14163 Berlin, Germany.,Robert Koch Institute, PO Box 65 02 61, D-13302 Berlin, Germany
| | - Stefan Hagel
- Center for Infectious Diseases and Infection Control, Jena University Hospital, Am Klinikum 1, D-07747 Jena, Germany
| | - Mathias W Pletz
- Center for Infectious Diseases and Infection Control, Jena University Hospital, Am Klinikum 1, D-07747 Jena, Germany
| | - Jochen Gensichen
- Institute of General Practice and Family Medicine, Jena University Hospital, Bachstrasse 18, D-07743 Jena, Germany
| | - Petra Gastmeier
- Institute of Hygiene and Environmental Medicine, Charité University Medical Center Berlin, Hindenburgdamm 27, D-12203 Berlin, Germany
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Mangel an Informationen und deren Bereitstellung am Arbeitsplatz als mögliche Gründe für inkorrekte Antibiotikatherapien in Deutschland. ZEITSCHRIFT FUR EVIDENZ FORTBILDUNG UND QUALITAET IM GESUNDHEITSWESEN 2019; 144-145:35-41. [DOI: 10.1016/j.zefq.2019.06.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 04/08/2019] [Accepted: 06/17/2019] [Indexed: 11/18/2022]
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9
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Warreman EB, Lambregts MMC, Wouters RHP, Visser LG, Staats H, van Dijk E, de Boer MGJ. Determinants of in-hospital antibiotic prescription behaviour: a systematic review and formation of a comprehensive framework. Clin Microbiol Infect 2018; 25:538-545. [PMID: 30267927 DOI: 10.1016/j.cmi.2018.09.006] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 08/26/2018] [Accepted: 09/10/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Knowledge of determinants that influence antibiotic prescription behaviour (APB) is essential for the successful implementation of antimicrobial stewardship interventions. The theory of planned behaviour (TPB) is an established model that describes how cognitions drive human behaviour. OBJECTIVES The objective of this study was to identify the sociocultural and behavioural determinants that affect APB and to construct a TPB framework of behavioural intent. METHODS The following online databases were searched: PubMed, Medline, Embase, Web of Science, Cochrane Library and Central. Studies published between July 2010 and July 2017 in European countries, the United States, Canada, New Zealand or Australia were included if they identified one or more determinants of physicians' APB. A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Based on the TPB, determinants were categorized in behavioural, normative and control beliefs, thus shaping a conceptual framework for APB. RESULTS Nine studies were eligible for inclusion, and 16 determinants were identified. Determinants relating to fear of adverse outcome (5/9), tolerance of risk and uncertainty (5/9), hierarchy (6/9), and determinants concerning normative beliefs-particularly social team dynamics (6/9)-were most frequently reported. Beliefs about antimicrobial resistance and potential negative consequences of antibiotic use were rarely mentioned. CONCLUSIONS Behavioural, normative and control beliefs are all relevant in APB. There is a need for quantitative studies to assess the weight of the individual determinants to be able to efficiently design and implement future stewardship interventions. The constructed framework enables a comprehensive approach towards understanding and altering APB.
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Affiliation(s)
- E B Warreman
- Department of Infectious Diseases, Leiden University Medical Centre, The Netherlands
| | - M M C Lambregts
- Department of Infectious Diseases, Leiden University Medical Centre, The Netherlands.
| | - R H P Wouters
- Department of Medical Humanities, Utrecht University Medical Centre, The Netherlands
| | - L G Visser
- Department of Infectious Diseases, Leiden University Medical Centre, The Netherlands
| | - H Staats
- Faculty of Social and Behavioural Sciences, Leiden University, The Netherlands
| | - E van Dijk
- Faculty of Social and Behavioural Sciences, Leiden University, The Netherlands
| | - M G J de Boer
- Department of Infectious Diseases, Leiden University Medical Centre, The Netherlands
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Salm F, Schneider S, Schmücker K, Petruschke I, Kramer TS, Hanke R, Schröder C, Heintze C, Schwantes U, Gastmeier P, Gensichen J. Antibiotic prescribing behavior among general practitioners - a questionnaire-based study in Germany. BMC Infect Dis 2018; 18:208. [PMID: 29728063 PMCID: PMC5935909 DOI: 10.1186/s12879-018-3120-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 04/30/2018] [Indexed: 12/18/2022] Open
Abstract
Background This study investigates the barriers and facilitators of the use of antibiotics in acute respiratory tract infections by general practitioners (GPs) in Germany. Methods A multidisciplinary team designed and pre-tested a written questionnaire addressing the topics awareness of antimicrobial resistance (7 items), use of antibiotics (9 items), guidelines/sources of information (9 items) and sociodemographic factors (7 items), using a five-point-Likert-scale (“never” to “very often”). The questionnaire was mailed by postally to 987 GPs with registered practices in eastern Germany in May 2015. Results 34% (340/987) of the GPs responded to this survey. Most of the participants assumed a multifactorial origin for the rise of multidrug resistant organisms. In addition, 70.2% (239/340) believed that their own prescribing behavior influenced the drug-resistance situation in their area. GPs with longer work experience (> 25 years) assumed less individual influence on drug resistance than their colleagues with less than 7 years experience as practicing physicians (Odds Ratio [OR] 0.32, 95% Confidence Interval [CI] 0.17–0.62; P < 0.001). 99.1% (337/340) of participants were familiar with the “delayed prescription” strategy to reduce antibiotic prescriptions. However, only 29.4% (74/340) answered that they apply it “often” or “very often”. GPs working in rural areas were less likely than those working in urban areas to apply delayed prescription. Conclusion The knowledge on factors causing antimicrobial resistance in bacteria is good among GPs in eastern Germany. However measures to improve rational prescription are not widely implemented yet. Further efforts have to be made in order to improve rational prescription of antibiotic among GPs. Nevertheless, there is a strong awareness of antimicrobial resistance among the participating GPs. Electronic supplementary material The online version of this article (10.1186/s12879-018-3120-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Florian Salm
- Institute for Infection Prevention and Hospital Epidemiology, Medical Center - University of Freiburg, Breisacher Str. 115 B, D-79106, Freiburg, Germany. .,Institute of Hygiene and Environmental Medicine, Charité University Medical Center Berlin, German National Reference Center for the Surveillance of Nosocomial Infections, Hindenburgdamm 27, D-12203, Berlin, Germany.
| | - Sandra Schneider
- Institute of Hygiene and Environmental Medicine, Charité University Medical Center Berlin, German National Reference Center for the Surveillance of Nosocomial Infections, Hindenburgdamm 27, D-12203, Berlin, Germany
| | - Katja Schmücker
- Institute of General Practice and Family Medicine, Jena University Hospital, Friedrich-Schiller-University, School of Medicine, Bachstrasse 18, D-07743, Jena, Germany
| | - Inga Petruschke
- Institute of General Practice and Family Medicine, Jena University Hospital, Friedrich-Schiller-University, School of Medicine, Bachstrasse 18, D-07743, Jena, Germany
| | - Tobias S Kramer
- Institute of Hygiene and Environmental Medicine, Charité University Medical Center Berlin, German National Reference Center for the Surveillance of Nosocomial Infections, Hindenburgdamm 27, D-12203, Berlin, Germany
| | - Regina Hanke
- Institute of Hygiene and Environmental Medicine, Charité University Medical Center Berlin, German National Reference Center for the Surveillance of Nosocomial Infections, Hindenburgdamm 27, D-12203, Berlin, Germany.,Lindgrün GmbH, Cuxhavener Strasse 12, D-10555, Berlin, Germany
| | - Christin Schröder
- Institute of Hygiene and Environmental Medicine, Charité University Medical Center Berlin, German National Reference Center for the Surveillance of Nosocomial Infections, Hindenburgdamm 27, D-12203, Berlin, Germany
| | - Christoph Heintze
- Institute Institute for General Practice and Family Medicine, Charité University Medical Center Berlin, Charitéplatz 1, D-10117, Berlin, Germany
| | - Ulrich Schwantes
- Medizinische Hochschule Brandenburg Theodor Fontane, Fehrbelliner Str. 38, D-16816, Neuruppin, Germany
| | - Petra Gastmeier
- Institute of Hygiene and Environmental Medicine, Charité University Medical Center Berlin, German National Reference Center for the Surveillance of Nosocomial Infections, Hindenburgdamm 27, D-12203, Berlin, Germany
| | - Jochen Gensichen
- Institute for General Practice, Ludwig-Maxilmilians-University/University Hospital, Pettenkofer str.8/10, D-80336, Munich, Germany
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Abele-Horn M, Pantke E, Eckmanns T. Wege zum fachgerechten und verantwortungsvollen Umgang mit Antibiotika. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2018; 61:572-579. [DOI: 10.1007/s00103-018-2723-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Hueber S, Kuehlein T, Gerlach R, Tauscher M, Schedlbauer A. "What they see is what you get": Prescribing antibiotics for respiratory tract infections in primary care: Do high prescribers diagnose differently? An analysis of German routine data. PLoS One 2017; 12:e0188521. [PMID: 29220399 PMCID: PMC5722345 DOI: 10.1371/journal.pone.0188521] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 11/08/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Characteristics of high and low prescribers of antibiotics in German primary care were analysed using population data. We aimed to evaluate differences in prescribing rates and factors being associated with high prescribing, and whether high prescribers made the diagnosis of perceived bacterial infections more often. METHODS Routine data were provided by the Bavarian Association of Statutory Health Insurance Physicians. Routine data are delivered by primary care practices on a quarterly basis. We analysed data from 2011 and 2012. Patients older than 15 years with respiratory tract infections consulting a primary care physician were selected (6.647 primary care practices). Patient and physician characteristics associated with high prescribing were identified using stepwise logistic regression. RESULTS Mean prescribing rate of antibiotics was 24.9%. Prescribing rate for high prescribers was 43.5% compared to 8.5% for low prescribers. High prescribers made the diagnosis of perceived bacterial infections more often (Mhigh = 64.5%, Mlow = 45.2%). In the adjusted regression model, perceived bacterial infections were strongly associated with high prescribing (OR = 13.9, 95% CI [10.2, 18.8]). Treating patients with comorbidities was associated with lower prescribing of antibiotics (OR = 0.6, 95% CI [0.4, 0.8]). High prescribers had a higher practice volume, a higher degree of prescribing dominance, and were situated more often in deprived areas and in rural settings. INTERPRETATION Compared to findings of studies in other European countries, prescribing rates were low. There was a considerable difference between prescribing rates of high and low prescribers. Diagnostic labelling was the best predictor for high prescribing. Current guidelines recommend considering antibiotic treatment for patients with co-morbidities. In our study, treating a large number of high-risk patients was not associated with high prescribing.
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Affiliation(s)
- Susann Hueber
- Universitätsklinikum Erlangen, Institute of General Practice, Erlangen, Germany
- * E-mail:
| | - Thomas Kuehlein
- Universitätsklinikum Erlangen, Institute of General Practice, Erlangen, Germany
| | - Roman Gerlach
- Kassenärztliche Vereinigung Bayern, München, Germany
| | | | - Angela Schedlbauer
- Universitätsklinikum Erlangen, Institute of General Practice, Erlangen, Germany
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Laupland KB, Ruppé E, Harbarth S. In 2035, will all bacteria be multidrug resistant? We are not sure. Intensive Care Med 2016; 42:2021-2023. [PMID: 27091440 DOI: 10.1007/s00134-016-4343-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Accepted: 03/23/2016] [Indexed: 12/19/2022]
Affiliation(s)
- Kevin B Laupland
- Department of Medicine, Royal Inland Hospital, 311 Columba Street, Kamloops, BC, V2C 2T1, Canada.
| | - Etienne Ruppé
- Genomic Research Laboratory, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Stephan Harbarth
- Infection Control Programme, Hôpitaux Universitaires de Genève, Geneva, Switzerland
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Pereko DD, Lubbe MS, Essack SY. Antibiotic use in Namibia: prescriber practices for common community infections. S Afr Fam Pract (2004) 2015. [DOI: 10.1080/20786190.2015.1024021] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Knudsen HK, Roman PM. The transition to medication adoption in publicly funded substance use disorder treatment programs: organizational structure, culture, and resources. J Stud Alcohol Drugs 2014; 75:476-85. [PMID: 24766760 DOI: 10.15288/jsad.2014.75.476] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Medications for the treatment of substance use disorders (SUDs) are not widely available in publicly funded SUD treatment programs. Few studies have drawn on longitudinal data to examine the organizational characteristics associated with programs transitioning from not delivering any pharmacotherapy to adopting at least one SUD medication. METHOD Using two waves of panel longitudinal data collected over a 5-year period, we measured the transition to medication adoption in a cohort of 190 publicly funded treatment organizations that offered no SUD medications at baseline. Independent variables included organizational characteristics, medical resources, funding, treatment culture, and detailing activities by pharmaceutical companies. RESULTS Of 190 programs not offering SUD pharmacotherapy at baseline, 22.6% transitioned to offering at least one SUD medication at follow-up approximately 5 years later. Multivariate logistic regression results indicated that the employment of at least one physician at baseline, having a greater proportion of Medicaid clients, and pharmaceutical detailing were positively associated with medication adoption. CONCLUSIONS Adoption of pharmacotherapy was more likely in programs that had greater medical resources, Medicaid funding, and contact with pharmaceutical companies. Given the potential expansion of Medicaid under the Affordable Care Act, patients served by publicly funded programs may gain greater access to such treatments, but research is needed to document health reform's impact on this sector of the treatment system.
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Affiliation(s)
- Hannah K Knudsen
- Department of Behavioral Science, University of Kentucky, Lexington, Kentucky
| | - Paul M Roman
- Owens Institute for Behavioral Research and Department of Sociology, University of Georgia, Athens, Georgia
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Velasco E. In reply. DEUTSCHES ARZTEBLATT INTERNATIONAL 2013; 110:328. [PMID: 23720702 PMCID: PMC3659966 DOI: 10.3238/arztebl.2013.0328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
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Velasco E, Noll I, Espelage W, Ziegelmann A, Krause G, Eckmanns T. A survey of outpatient antibiotic prescribing for cystitis. DEUTSCHES ARZTEBLATT INTERNATIONAL 2012; 109:878-84. [PMID: 23293677 PMCID: PMC3536042 DOI: 10.3238/arztebl.2012.0878] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2011] [Accepted: 09/17/2012] [Indexed: 11/27/2022]
Abstract
BACKGROUND In view of the currently increasing rates of antibiotic resistance, we studied the factors that affect the prescribing of specific antibiotics for uncomplicated cystitis in outpatient care. METHODS A nationwide cross-sectional survey of physicians in private practice in various specialties (internal medicine, general medicine, surgery, obstetrics/gynecology, child and adolescent medicine, otorhinolaryngology, dermatology, urology) was carried out in 2008. The sample was derived from the German state directories of medical specialists. RESULTS 1810 (60%) of the physicians surveyed reported that they made decisions about antibiotic treatment every day, with uncomplicated urinary tract infection as the most common diagnosis (715 physicians). The antibiotics that they prescribed most commonly for it were cotrimoxazole (61%) and fluoroquinolones (21%). The following factors were significantly associated with a preference for fluoroquinolones: being a gynecologist (odds ratio [OR] 0.47, 95% confidence interval [CI] 0.27-0.80), location of practice in the former East Germany (OR 2.01, CI 1.16-3.46), a treatment strategy incorporating a switch from empirical to targeted treatment (OR 1.72, CI 1.02-2.90), and the stated intention of avoiding inconvenience to the patient (OR 2.14, CI 1.25-3.68). DISCUSSION Fluoroquinolones are no longer recommended as the drug of first choice for uncomplicated urinary tract infections because of the development of resistance, but are still commonly prescribed for it. ARS (Antibiotic Resistance Surveillance in Germany) publishes current regional and patient-group-specific resistance rates to promote good clinical practice and improve prescribing behavior.
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Velasco E, Ziegelmann A, Eckmanns T, Krause G. Eliciting views on antibiotic prescribing and resistance among hospital and outpatient care physicians in Berlin, Germany: results of a qualitative study. BMJ Open 2012; 2:e000398. [PMID: 22307097 PMCID: PMC3274716 DOI: 10.1136/bmjopen-2011-000398] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To better understand physicians' views on factors of influence for the prescribing of antibiotics and on antibiotic resistance in the Berlin region, Germany. DESIGN Qualitative study with focus groups. SETTING Outpatient care and hospital care practice in the Berlin region, Germany. PARTICIPANTS 7 General practitioners, two urologists, one paediatrician from outpatient care and eight internists, two paediatricians, two ear, nose and throat specialists and two urologists from hospital care. RESULTS Physicians showed differential interest in topics related to antibiotic prescribing and antibiotic resistance. Outpatient care physicians were interested in topics around their own prescribing, such as being able to diagnose and prescribe precisely, and topics about patient demand and non-compliance. Hospital care physicians were interested in hygiene challenges, limited consult time and multi-resistant pathogens. CONCLUSIONS Physicians considered the development of resistance to be more in the domain of clinical treatment than that of the patient. Major challenges related to antibiotic resistance for this group of physicians are access to and clarity of treatment recommendations, implementation of hygienic measures, as well as increased outsourcing of laboratory services. Results raise questions about whether meeting physicians' expectations should be a focus when developing intervention that aims to influence antibiotic resistance in this and other areas of Germany.
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Affiliation(s)
- Edward Velasco
- Department for Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
- Faculty of Medicine, Charité—University Hospital Berlin, Berlin, Germany
| | - Antina Ziegelmann
- Division for Communicable Diseases, AIDS, Prevention of Epidemics, Federal Ministry of Health, Berlin, Germany
| | - Tim Eckmanns
- Department for Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
| | - Gérard Krause
- Department for Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
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Ruef C. Why do physicians prescribe antibiotics? Infection 2011; 39:287. [DOI: 10.1007/s15010-011-0169-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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