Cluster-randomized trial to improve antibiotic use for adults with acute respiratory infections treated in emergency departments

Do all Emergency Room Patients With Influenza-like Symptoms Need Blood Cultures? A Retrospective Cohort Study of 2 Annual Influenza Seasons

In this retrospective cohort study, we evaluated risk factors for bacteremia in emergency department patients presenting with influenza-like symptoms during influenza epidemic seasons. In patients without fever, chronic heart or chronic liver disease, blood culture collection might be omitted.

The Challenges of The Diagnostic and Therapeutic Approach of Patients with Infectious Pathology in Emergency Medicine

The emergency department (ED) represents an important setting for addressing inappropriate antimicrobial prescribing practices because of the time constraints and the duration of microbiological diagnosis. The purpose of this study is to evaluate the etiology and antimicrobial resistance (AMR) pattern of the community-acquired pathogens, as well as the epidemiological characteristics of patients admitted through the ED, in order to guide appropriate antibiotic therapy.

METHODS

A retrospective observational study was performed on 657 patients, from whom clinical samples (urine, purulent secretions, blood cultures, etc.) were collected for microbiological diagnosis in the first 3 days after presentation in the ED. The identification of pathogens and the antimicrobial susceptibility testing with minimum inhibitory concentration determination were carried out according to the laboratory protocols.

RESULTS

From the 767 biological samples analyzed, 903 microbial isolates were identified. E. coli was most frequently isolated (24.25%), followed by Klebsiella spp., S. aureus (SA), and non-fermentative Gram-negative bacilli. E. coli strains maintained their natural susceptibility to most antibiotics tested. In the case of Pseudomonas spp. and Acinetobacter spp., increased rates of AMR were identified. Also, 32.3% of SA strains were community-acquired MRSA.

CONCLUSIONS

The introduction of rapid microbiological diagnostic methods in emergency medicine is imperative in order to timely identify AMR strains and improve therapeutic protocols.

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.

The Interventions and Challenges of Antimicrobial Stewardship in the Emergency Department

Over the last decades, we have witnessed a constant increase in infections caused by multi-drug-resistant strains in emergency departments. Despite the demonstrated effectiveness of antimicrobial stewardship programs in antibiotic consumption and minimizing multi-drug-resistant bacterium development, the characteristics of emergency departments pose a challenge to their implementation. The inclusion of rapid diagnostic tests, tracking microbiological results upon discharge, conducting audits with feedback, and implementing multimodal educational interventions have proven to be effective tools for optimizing antibiotic use in these units. Nevertheless, future multicenter studies are essential to determine the best way to proceed and measure outcomes in this scenario.

Effectiveness of de-implementation strategies for low-value prescribing in secondary care: a systematic review

BACKGROUND/AIMS

Considerable efforts have been made to improve guideline adherence in healthcare through de-implementation, such as decreasing the prescription of inappropriate medicines. However, we have limited knowledge about the effectiveness, barriers, facilitators and consequences of de-implementation strategies targeting inappropriate medication prescribing in secondary care settings. This review was conducted to understand these factors to contribute to better replication and optimisation of future de-implementation efforts to reduce low-value care.

METHODS

A systematic review of randomised control trials was conducted. Papers were identified through CINAHL, EMBASE, MEDLINE and Cochrane register of controlled trials to February 2021. Eligible studies were randomised control trials evaluating behavioural strategies to de-implement inappropriate prescribing in secondary healthcare. Risk of bias was assessed using the Cochrane Risk of Bias tool. Intervention characteristics, effectiveness, barriers, facilitators and consequences were identified in the study text and tabulated.

RESULTS

Eleven studies were included, of which seven were reported as effectively de-implementing low-value prescribing. Included studies were judged to be mainly at low to moderate risk for selection biases and generally high risk for performance and reporting biases. The majority of these strategies were clinical decision support at the 'point of care'. Clinical decision support tools were the most common and effective. They were found to be a low-cost and simple strategy. However, barriers such as clinician's reluctance to accept recommendations, or the clinical setting were potential barriers to their success. Educational strategies were the second most reported intervention type however the utility of educational strategies for de-implementation remains varied. Multiple barriers and facilitators relating to the environmental context, resources and knowledge were identified across studies as potentially influencing de-implementation. Various consequences were identified; however, few measured the impact of de-implementation on usual appropriate practice.

CONCLUSION

This review offers insight into the intervention strategies, potential barriers, facilitators and consequences that may affect the de-implementation of low-value prescribing in secondary care. Identification of these key features helps understand how and why these strategies are effective and the wider (desirable or undesirable) impact of de-implementation. These findings can contribute to the successful replication or optimisation of strategies used to de-implement low-value prescribing practices in future.

TRIAL REGISTRATION

The review protocol was registered at PROSPERO (ID: CRD42021243944).

Prevalence and appropriateness of in-person versus not-in-person ambulatory antibiotic prescribing in an integrated academic health system: A cohort study

OBJECTIVES

Ambulatory antibiotic stewardship generally aims to address the appropriateness of antibiotics prescribed at in-person visits. The prevalence and appropriateness of antibiotics prescribed outside of in-person visits is poorly studied.

DESIGN AND SETTING

Retrospective cohort study of all ambulatory antibiotic prescribing in an integrated health delivery system in the United States.

PARTICIPANTS

Antibiotic prescribers and patients receiving oral antibiotic prescriptions between January 2016 and December 2019.

MAIN OUTCOME MEASURES

Proportion of antibiotics prescribed with in-person visits or not-in-person encounters (e.g., telephone, refills). Proportion of prescriptions in in 5 mutually exclusive appropriateness groups: 1) chronic antibiotic use; 2) antibiotic-appropriate; 3) potentially antibiotic-appropriate; 4) non-antibiotic-appropriate; and 5) not associated with a diagnosis.

RESULTS

Over the 4-year study period, there were 714,057 antibiotic prescriptions ordered for 348,739 unique patients by 2,391 clinicians in 467 clinics. Patients had a mean age of 41 years old, were 61% female, and 78% White. Clinicians were 58% women; 78% physicians; and were 42% primary care, 39% medical specialists, and 12% surgical specialists. Overall, 81% of antibiotics were prescribed with in-person visits and 19% without in-person visits. The most common not-in-person encounter types were telephone (10%), orders only (5%), and refill encounters (3%). Of all antibiotic prescriptions, 16% were for chronic use, 15% were antibiotic-appropriate, 39% were potentially antibiotic-appropriate, 22% were non-antibiotic-appropriate, and 8% were not associated with a diagnosis. Antibiotics prescribed in not-in-person encounters were more likely to be chronic (20% versus 15%); less likely to be associated with appropriate or potentially appropriate diagnoses (30% versus 59%) or non-antibiotic-appropriate diagnoses (8% versus 25%); and more likely to be associated with no diagnosis (42% versus <1%).

CONCLUSIONS

Ambulatory stewardship interventions that focus only on in-person visits may miss a large proportion of antibiotic prescribing, inappropriate prescribing, and antibiotics prescribed in the absence of any diagnosis.

Pattern of antibiotic use and bacterial co-infection in hospitalized Covid-19 patients

Background

There is evidence that bacterial co-infection in respiratory viruses leads to morbidity and mortality. Patients with decreased immunity are prone to bacterial co-infection. A lack of judicious use of antibiotics leads to the spread of multi-drug resistant bacteria (MDR) that have a long-term negative impact. In this study, we attempted to observe the pattern of antibacterial use and its impact on secondary bacterial infection.

Methods

An observational study was conducted at Alexandria Main University Hospital (AMUH) (Alexandria University) from June 2021- February 2022. Study participants were admitted to the Intensive Care Unit (ICU) with confirmed Covid-19 (by Polymerase Chain Reaction (PCR) and Computed tomography (CT) scan). The following data was collected (Demographic, clinical, and laboratory data).In this study, the Pattern of antibiotic use as well as the occurrence of secondary bacterial infections were reported.

Results

Among 121 patients included in the present study, all received antibiotics empirically. Upon admission (19.8%) showed urinary tract infection, (11.5%) had bloodstream infection, and (57.7%) had respiratory tract infection. After 10 days secondary bacterial infection occurred in 38 patients (61.2%) with (24.1%) Urinary tract infection (UTI), (12.9%) Bloodstream infection (BSI), and (72.2%) respiratory tract infection. The respiratory sample size was (45) patients due to Infection Control (IC) restrictions on the aerosol-producing procedure.

Conclusion

Upon admission, all patients received broad-spectrum antibiotics while the incidence of bacterial co-infection was low.

Effect of unifaceted and multifaceted interventions on antibiotic prescription control for respiratory diseases: A systematic review of randomized controlled trials

BACKGROUND

The global health system is improperly using antibiotics, particularly in the treatment of respiratory diseases. We aimed to examine the effectiveness of implementing a unifaceted and multifaceted intervention for unreasonable antibiotic prescriptions.

METHODS

Relevant literature published in the databases of Pubmed, Embase, Science Direct, Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure and Wanfang was searched. Data were independently filtered and extracted by 2 reviewers based on a pre-designed inclusion and exclusion criteria. The Cochrane collaborative bias risk tool was used to evaluate the quality of the included randomized controlled trials studies.

RESULTS

A total of 1390 studies were obtained of which 23 studies the outcome variables were antibiotic prescription rates with the number of prescriptions and intervention details were included in the systematic review. Twenty-two of the studies involved educational interventions for doctors, including: online training using email, web pages and webinar, antibiotic guidelines for information dissemination measures by email, postal or telephone reminder, training doctors in communication skills, short-term interactive educational seminars, and short-term field training sessions. Seventeen studies of interventions for health care workers also included: regular or irregular assessment/audit of antibiotic prescriptions, prescription recommendations from experts and peers delivered at a meeting or online, publicly reporting on doctors' antibiotic usage to patients, hospital administrators, and health authorities, monitoring/feedback prescribing behavior to general practices by email or poster, and studies involving patients and their families (n = 8). Twenty-one randomized controlled trials were rated as having a low risk of bias while 2 randomized controlled trials were rated as having a high risk of bias. Six studies contained negative results.

CONCLUSION

The combination of education, prescription audit, prescription recommendations from experts, public reporting, prescription feedback and patient or family member multifaceted interventions can effectively reduce antibiotic prescription rates in health care institutions. Moreover, adding multifaceted interventions to educational interventions can control antibiotic prescription rates and may be a more reasonable method.

REGISTRATIONS

This systematic review was registered in PROSPERO, registration number: CRD42020192560.

Systematic review of determinants influencing antibiotic prescribing for uncomplicated acute respiratory tract infections in adult patients at the emergency department

OBJECTIVE

Overuse of antibiotics in the emergency department (ED) for uncomplicated acute respiratory tract infections (uARTIs) is a public health issue that needs to be addressed. We aimed to identify factors associated with antibiotic use for uARTIs in adults presenting at the ED.

DESIGN

We searched Medline, Embase, PsycINFO and the Cochrane Library for articles published from 1 January 2005 to 30 June 2017 using a predetermined search strategy. Titles and abstracts of English articles on antibiotic prescription and inappropriate antibiotic use for adult ARTI at EDs were assessed, followed by full article review, by 2 authors.

SETTING

Emergency departments.

PARTICIPANTS

Adults aged 18 years and older.

RESULTS

Of the 2,591 articles retrieved, 12 articles met the inclusion criteria and 11 studies were conducted in the United States. Patients with normal C-reactive protein levels and positive influenza tests were less likely to receive antibiotic treatment. Nonclinical factors associated with antibiotic use were longer waiting time and perceived patient desire for antibiotics. Patients attended by internal medicine physicians comanaged by house staff or who visited an ED which provided education to healthcare providers on antibiotics use were less likely to receive antibiotics.

CONCLUSIONS

English-language articles that fulfilled the selection criteria outside the United States were limited. Factors associated with antibiotics use are multifaceted. Education of healthcare providers presents an opportunity to improve antibiotic use.

Changing antibiotic prescribing practices in outpatient primary care settings in China: Study protocol for a health information system-based cluster-randomised crossover controlled trial

Background

The overuse and abuse of antibiotics is a major risk factor for antibiotic resistance in primary care settings of China. In this study, the effectiveness of an automatically-presented, privacy-protecting, computer information technology (IT)-based antibiotic feedback intervention will be evaluated to determine whether it can reduce antibiotic prescribing rates and unreasonable prescribing behaviours.

Methods

We will pilot and develop a cluster-randomised, open controlled, crossover, superiority trial. A total of 320 outpatient physicians in 6 counties of Guizhou province who met the standard will be randomly divided into intervention group and control group with a primary care hospital being the unit of cluster allocation. In the intervention group, the three components of the feedback intervention included: 1. Artificial intelligence (AI)-based real-time warnings of improper antibiotic use; 2. Pop-up windows of antibiotic prescription rate ranking; 3. Distribution of educational manuals. In the control group, no form of intervention will be provided. The trial will last for 6 months and will be divided into two phases of three months each. The two groups will crossover after 3 months. The primary outcome is the 10-day antibiotic prescription rate of physicians. The secondary outcome is the rational use of antibiotic prescriptions. The acceptability and feasibility of this feedback intervention study will be evaluated using both qualitative and quantitative assessment methods.

Discussion

This study will overcome limitations of our previous study, which only focused on reducing antibiotic prescription rates. AI techniques and an educational intervention will be used in this study to effectively reduce antibiotic prescription rates and antibiotic irregularities. This study will also provide new ideas and approaches for further research in this area.

Trial registration

ISRCTN, ID: ISRCTN13817256. Registered on 11 January 2020.

Implementation of Veterans Affairs Primary Care Antimicrobial Stewardship Interventions For Asymptomatic Bacteriuria And Acute Respiratory Infections

Background

Outpatient antimicrobial prescribing is an important target for antimicrobial stewardship (AMS) interventions to decrease antimicrobial resistance. The objective of this study was to design, implement, and evaluate the impact of AMS interventions focused on asymptomatic bacteriuria (ASB) and acute respiratory infections (ARIs) in the primary care setting.

Methods

This stepped-wedge trial evaluated the impact of multifaceted educational interventions to providers on adult patients presenting to primary care clinics for ARIs and ASB. The primary outcome was percentage of overall antibiotic prescriptions as a composite of prescriptions for ASB, acute bronchitis, upper respiratory infection not otherwise specified, uncomplicated sinusitis, and uncomplicated pharyngitis. Secondary outcomes were the individual components of the primary outcome; a composite safety endpoint of related hospital, emergency department, or primary care visits within 4 weeks; antibiotic selection appropriateness; and patient satisfaction surveys.

Results

A total of 887 patients were included (405 preintervention and 482 postintervention). After controlling for type I error using Bonferroni correction, the primary outcome was not significantly different between groups (56% vs 49%). There was a statistically significant decrease in prescriptions for acute bronchitis (20.99% vs 12.66%; P = .0003). Appropriateness of antibiotic prescriptions for uncomplicated sinusitis (odds ratio [OR], 4.96 [95% confidence interval {CI}, 1.79–13.75]; P = .0021) and pharyngitis (OR, 5.36 [95% CI, 1.93–14.90]; P = .0013) was improved in the postintervention vs the preintervention group. The composite safety outcome and patient satisfaction surveys did not differ between groups.

Conclusions

Multifaceted educational interventions targeting providers can improve antibiotic prescribing for indications rarely requiring antimicrobials without increasing re-visits or patient satisfaction surveys.

Continuing education meetings and workshops: effects on professional practice and healthcare outcomes

BACKGROUND

Educational meetings are used widely by health personnel to provide continuing medical education and to promote implementation of innovations or translate new knowledge to change practice within healthcare systems. Previous reviews have concluded that educational meetings can result in small changes in behaviour, but that effects vary considerably. Investigations into which characteristics of educational meetings might lead to greater impact have yielded varying results, and factors that might explain heterogeneity in effects remain unclear. This is the second update of this Cochrane Review.

OBJECTIVES

• To assess the effects of educational meetings on professional practice and healthcare outcomes • To investigate factors that might explain the heterogeneity of these effects SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, ERIC, Science Citation Index Expanded (ISI Web of Knowledge), and Social Sciences Citation Index (last search in November 2016).

SELECTION CRITERIA

We sought randomised trials examining the effects of educational meetings on professional practice and patient outcomes.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risk of bias. One review author assessed the certainty of evidence (GRADE) and discussed with a second review author. We included studies in the primary analysis that reported baseline data and that we judged to be at low or unclear risk of bias. For each comparison of dichotomous outcomes, we measured treatment effect as risk difference adjusted for baseline compliance. We expressed adjusted risk difference values as percentages, and we noted that values greater than zero favour educational meetings. For continuous outcomes, we measured treatment effect as per cent change relative to the control group mean post test, adjusted for baseline performance; we expressed values as percentages and noted that values greater than zero favour educational meetings. We report means and 95% confidence intervals (CIs) and, when appropriate, medians and interquartile ranges to facilitate comparisons to previous versions of this review. We analysed professional and patient outcomes separately and analysed 22 variables that were hypothesised a priori to explain heterogeneity. We explored heterogeneity by using univariate meta-regression and by inspecting violin plots.

MAIN RESULTS

We included 215 studies involving more than 28,167 health professionals, including 142 new studies for this update. Educational meetings as the single intervention or the main component of a multi-faceted intervention compared with no intervention • Probably slightly improve compliance with desired practice when compared with no intervention (65 comparisons, 7868 health professionals for dichotomous outcomes (adjusted risk difference 6.79%, 95% CI 6.62% to 6.97%; median 4.00%; interquartile range 0.29% to 13.00%); 28 comparisons, 2577 health professionals for continuous outcomes (adjusted relative percentage change 44.36%, 95% CI 41.98% to 46.75%; median 20.00%; interquartile range 6.00% to 65.00%)) • Probably slightly improve patient outcomes compared with no intervention (15 comparisons, 2530 health professionals for dichotomous outcomes (adjusted risk difference 3.30%, 95% CI 3.10% to 3.51%; median 0.10%; interquartile range 0.00% to 4.00%); 28 comparisons, 2294 health professionals for continuous outcomes (adjusted relative percentage change 8.35%, 95% CI 7.46% to 9.24%; median 2.00%; interquartile range -1.00% to 21.00%)) The certainty of evidence for this comparison is moderate. Educational meetings alone compared with other interventions • May improve compliance with desired practice when compared with other interventions (6 studies, 1402 health professionals for dichotomous outcomes (adjusted risk difference 9.99%, 95% CI 9.47% to 10.52%; median 16.5%; interquartile range 0.80% to 16.50%); 2 studies, 72 health professionals for continuous outcomes (adjusted relative percentage change 12.00%, 95% CI 9.16% to 14.84%; median 12.00%; interquartile range 0.00% to 24.00%)) No studies met the inclusion criteria for patient outcome measurements. The certainty of evidence for this comparison is low. Interactive educational meetings compared with didactic (lecture-based) educational meetings • We are uncertain of effects on compliance with desired practice (3 studies, 370 health professionals for dichotomous outcomes; 1 study, 192 health professionals for continuous outcomes) or on patient outcomes (1 study, 54 health professionals for continuous outcomes), as the certainty of evidence is very low Any other comparison of different formats and durations of educational meetings • We are uncertain of effects on compliance with desired practice (1 study, 19 health professionals for dichotomous outcomes; 1 study, 20 health professionals for continuous outcomes) or on patient outcomes (1 study, 113 health professionals for continuous outcomes), as the certainty of evidence is very low. Factors that might explain heterogeneity of effects Meta-regression suggests that larger estimates of effect are associated with studies judged to be at high risk of bias, with studies that had unit of analysis errors, and with studies in which the unit of analysis was the provider rather than the patient. Improved compliance with desired practice may be associated with: shorter meetings; poor baseline compliance; better attendance; shorter follow-up; professionals provided with additional take-home material; explicit building of educational meetings on theory; targeting of low- versus high-complexity behaviours; targeting of outcomes with high versus low importance; goal of increasing rather than decreasing behaviour; teaching by opinion leaders; and use of didactic versus interactive teaching methods. Pre-specified exploratory analyses of behaviour change techniques suggest that improved compliance with desired practice may be associated with use of a greater number of behaviour change techniques; goal-setting; provision of feedback; provision for social comparison; and provision for social support. Compliance may be decreased by the use of follow-up prompts, skills training, and barrier identification techniques.

AUTHORS' CONCLUSIONS

Compared with no intervention, educational meetings as the main component of an intervention probably slightly improve professional practice and, to a lesser extent, patient outcomes. Educational meetings may improve compliance with desired practice to a greater extent than other kinds of behaviour change interventions, such as text messages, fees, or office systems. Our findings suggest that multi-strategy approaches might positively influence the effects of educational meetings. Additional trials of educational meetings compared with no intervention are unlikely to change the review findings; therefore we will not further update this review comparison in the future. However, we note that randomised trials comparing different types of education are needed.

A 29-mRNA host response test from blood accurately distinguishes bacterial and viral infections among emergency department patients

BACKGROUND

Whether or not to administer antibiotics is a common and challenging clinical decision in patients with suspected infections presenting to the emergency department (ED). We prospectively validate InSep, a 29-mRNA blood-based host response test for the prediction of bacterial and viral infections.

METHODS

The PROMPT trial is a prospective, non-interventional, multi-center clinical study that enrolled 397 adult patients presenting to the ED with signs of acute infection and at least one vital sign change. The infection status was adjudicated using chart review (including a syndromic molecular respiratory panel, procalcitonin and C-reactive protein) by three infectious disease physicians blinded to InSep results. InSep (version BVN-2) was performed using PAXgene Blood RNA processed and quantified on NanoString nCounter SPRINT. InSep results (likelihood of bacterial and viral infection) were compared to the adjudicated infection status.

RESULTS

Subject mean age was 64 years, comorbidities were significant for diabetes (17.1%), chronic obstructive pulmonary disease (13.6%), and severe neurological disease (6.8%); 16.9% of subjects were immunocompromised. Infections were adjudicated as bacterial (14.1%), viral (11.3%) and noninfected (0.25%): 74.1% of subjects were adjudicated as indeterminate. InSep distinguished bacterial vs. viral/noninfected patients and viral vs. bacterial/noninfected patients using consensus adjudication with AUROCs of 0.94 (95% CI 0.90-0.99) and 0.90 (95% CI 0.83-0.96), respectively. AUROCs for bacterial vs. viral/noninfected patients were 0.88 (95% CI 0.79-0.96) for PCT, 0.80 (95% CI 0.72-89) for CRP and 0.78 (95% CI 0.69-0.87) for white blood cell counts (of note, the latter biomarkers were provided as part of clinical adjudication). To enable clinical actionability, InSep incorporates score cutoffs to allocate patients into interpretation bands. The Very Likely (rule in) InSep bacterial band showed a specificity of 98% compared to 94% for the corresponding PCT band (> 0.5 µg/L); the Very Unlikely (rule-out) band showed a sensitivity of 95% for InSep compared to 86% for PCT. For the detection of viral infections, InSep demonstrated a specificity of 93% for the Very Likely band (rule in) and a sensitivity of 96% for the Very Unlikely band (rule out).

CONCLUSIONS

InSep demonstrated high accuracy for predicting the presence of both bacterial and viral infections in ED patients with suspected acute infections or suspected sepsis. When translated into a rapid, point-of-care test, InSep will provide ED physicians with actionable results supporting early informed treatment decisions to improve patient outcomes while upholding antimicrobial stewardship. Registration number at Clinicaltrials.gov NCT03295825.

Community-acquired bacteraemia in COVID-19 in comparison to influenza A and influenza B: a retrospective cohort study

Background

During the coronavirus disease 2019 (COVID-19) pandemic in the Netherlands it was noticed that very few blood cultures from COVID-19 patients turned positive with clinically relevant bacteria. This was particularly evident in comparison to the number of positive blood cultures during previous seasonal epidemics of influenza. This observation raised questions about the occurrence and causative microorganisms of bacteraemia in COVID-19 patients, especially in the perspective of the widely reported overuse of antibiotics and the rising rate of antibiotic resistance.

Methods

We conducted a retrospective cohort study on blood culture results in influenza A, influenza B and COVID-19 patients presenting to two hospitals in the Netherlands. Our main outcome consisted of the percentage of positive blood cultures. The percentage of clinically relevant blood cultures, isolated bacteria and 30-day all-cause mortality served as our secondary outcomes.

Results

A total of 1331 viral episodes were analysed in 1324 patients. There was no statistically significant difference (p = 0.47) in overall occurrence of blood culture positivity in COVID-19 patients (9.0, 95% CI 6.8–11.1) in comparison to influenza A (11.4, 95% CI 7.9–14.8) and influenza B patients (10.4, 95% CI 7.1–13.7,). After correcting for the high rate of contamination, the occurrence of clinically relevant bacteraemia in COVID-19 patients amounted to 1.0% (95% CI 0.3–1.8), which was statistically significantly lower (p = 0.04) compared to influenza A patients (4.0, 95% CI 1.9–6.1) and influenza B patients (3.0, 95% CI 1.2–4.9). The most frequently identified bacterial isolates in COVID-19 patients were Escherichia coli (n = 2) and Streptococcus pneumoniae (n = 2). The overall 30-day all-cause mortality for COVID-19 patients was 28.3% (95% CI 24.9–31.7), which was statistically significantly higher (p = <.001) when compared to patients with influenza A (7.1, 95% CI 4.3–9.9) and patients with influenza B (6.4, 95% CI 3.8–9.1).

Conclusions

We report a very low occurrence of community-acquired bacteraemia amongst COVID-19 patients in comparison to influenza patients. These results reinforce current clinical guidelines on antibiotic management in COVID-19, which only advise utilization of antibiotics when a bacterial co-infection is suspected.

Antimicrobial Resistance Patterns and Antibiotic Use during Hospital Conversion in the COVID-19 Pandemic

OBJECTIVE

To describe empirical antimicrobial prescription on admission in patients with severe COVID-19, the prevalence of Hospital-Acquired Infections, and the susceptibility patterns of the causing organisms.

METHODS

In this prospective cohort study in a tertiary care center in Mexico City, we included consecutive patients admitted with severe COVID-19 between March 20th and June 10th and evaluated empirical antimicrobial prescription and the occurrence of HAI.

RESULTS

794 patients with severe COVID-19 were admitted during the study period. Empiric antibiotic treatment was started in 92% of patients (731/794); the most frequent regimes were amoxicillin-clavulanate plus atypical coverage in 341 (46.6%) and ceftriaxone plus atypical coverage in 213 (29.1%). We identified 110 HAI episodes in 74/656 patients (11.3%). Ventilator-associated pneumonia (VAP) was the most frequent HAI, in 56/110 (50.9%), followed by bloodstream infections (BSI), in 32/110 (29.1%). The most frequent cause of VAP were Enterobacteriaceae in 48/69 (69.6%), followed by non-fermenter gram-negative bacilli in 18/69 (26.1%). The most frequent cause of BSI was coagulase negative staphylococci, in 14/35 (40.0%), followed by Enterobacter complex in 7/35 (20%). Death occurred in 30/74 (40.5%) patients with one or more HAI episodes and in 193/584 (33.0%) patients without any HAI episode (p < 0.05).

CONCLUSION

A high frequency of empiric antibiotic treatment in patients admitted with COVID-19 was seen. VAP and BSI were the most frequent hospital-acquired infections, due to Enterobacteriaceae and coagulase negative staphylococci, respectively.

Antimicrobial stewardship in the emergency department: characteristics and evidence for effectiveness of interventions

BACKGROUND

Emergency departments (EDs) are the entrance gates for patients presenting with infectious diseases into the hospital, yet most antimicrobial stewardship programmes are primarily focused on inpatient management. With equally high rates of inappropriate antibiotic use, the ED is a frequently overlooked yet important unit for targeted antimicrobial stewardship (AMS) interventions.

OBJECTIVES

We aimed to (a) describe the specific aspects of antimicrobial stewardship in the ED and (b) summarize the findings from improvement studies that have investigated the effectiveness of antimicrobial stewardship interventions in the ED setting.

SOURCES

(a) a PubMed search for 'antimicrobial stewardship' and 'emergency department', and (b) published reviews on effectiveness combined with publications from the first source.

CONTENT

(a) An in depth analysis of selected publications provided four key antimicrobial use processes typically performed by front-line healthcare professionals in the ED: making a (tentative) clinical diagnosis, starting empirical therapy based on that diagnosis, performing microbiological tests before starting that therapy and following up patients who are discharged from the ED. (b) Further, we discuss the literature on improvement strategies in the ED focusing on guidelines and clinical pathways and multifaceted improvement strategies. We also summarize the evidence of microbiologic culture review.

IMPLICATIONS

Based on our review of the literature, we describe four essential elements of antimicrobial use in the ED. Studying the various interventions targeting these care processes, we have found them to be of a variable degree of success. Nonetheless, while there is a paucity of AS studies specifically targeting the ED, there is a growing body of evidence that AS programmes in the ED are effective with modifications to the ED setting. We present key questions for future research.

A multifaceted intervention improves antibiotic stewardship for skin and soft tissues infections

OBJECTIVE

Assess the effectiveness of a multifaceted stewardship intervention to reduce frequency and duration of inappropriate antibiotic use for emergency department (ED) patients with skin and soft tissue infections (SSTI). We hypothesized the antibiotic stewardship program would reduce antibiotic duration and improve guideline adherence in discharged SSTI patients.

DESIGN

Nonrandomized controlled trial.

SETTING

Academic EDs (intervention site and control site).

PATIENTS OR PARTICIPANTS

Attending physicians and nurse practitioners at participating EDs.

INTERVENTION(S)

Education regarding guideline-based treatment of SSTI, tests of antimicrobial treatment of SSTI, implementation of a clinical treatment algorithm and order set in the electronic health record, and ED clinicians' audit and feedback.

RESULTS

We examined 583 SSTIs. At the intervention site, clinician adherence to guidelines improved from 41% to 51% (aOR = 2.13 [95% CI: 1.20-3.79]). At the control site, there were no changes in adherence during the "intervention" period (aOR = 1.17 [0.65-2.12]). The between-site comparison of these during vs. pre-intervention odds ratios was not different (aOR = 1.82 [0.79-4.21]). Antibiotic duration decreased by 26% at the intervention site during the intervention compared to pre-intervention (Adjusted Geometric Mean Ratio [95% CI] = 0.74 [0.66-0.84]). Adherence was inversely associated with SSTI severity (severe vs mild; adjusted OR 0.42 [0.20-0.89]) and purulence (0.32 [0.21-0.47]). Mean antibiotic prescription duration was 1.95 days shorter (95% CI: 1.54-2.33) in the time period following the intervention than pre-intervention period.

CONCLUSIONS

A multifaceted intervention resulted in modest improvement in adherence to guidelines compared to a control site, driven by treatment duration reductions.

Social norms interventions to change clinical behaviour in health workers: a systematic review and meta-analysis

Background

A social norms intervention seeks to change the clinical behaviour of a target health worker by exposing them to the values, beliefs, attitudes or behaviours of a reference group or person. These low-cost interventions can be used to encourage health workers to follow recommended professional practice.

Objective

To summarise evidence on whether or not social norms interventions are effective in encouraging health worker behaviour change, and to identify the most effective social norms interventions.

Design

A systematic review and meta-analysis of randomised controlled trials.

Data sources

The following databases were searched on 24 July 2018: Ovid MEDLINE (1946 to week 2 July 2018), EMBASE (1974 to 3 July 2018), Cumulative Index to Nursing and Allied Health Literature (1937 to July 2018), British Nursing Index (2008 to July 2018), ISI Web of Science (1900 to present), PsycINFO (1806 to week 3 July 2018) and Cochrane trials (up to July 2018).

Participants

Health workers took part in the study.

Interventions

Behaviour change interventions based on social norms.

Outcome measures

Health worker clinical behaviour, for example prescribing (primary outcome), and patient health outcomes, for example blood test results (secondary), converted into a standardised mean difference.

Methods

Titles and abstracts were reviewed against the inclusion criteria to exclude any that were clearly ineligible. Two reviewers independently screened the remaining full texts to identify relevant papers. Two reviewers extracted data independently, coded for behaviour change techniques and assessed quality using the Cochrane risk-of-bias tool. We performed a meta-analysis and presented forest plots, stratified by behaviour change technique. Sources of variation were explored using metaregression and network meta-analysis.

Results

A total of 4428 abstracts were screened, 477 full texts were screened and findings were based on 106 studies. Most studies were in primary care or hospitals, targeting prescribing, ordering of tests and communication with patients. The interventions included social comparison (in which information is given on how peers behave) and credible source (which refers to communication from a well-respected person in support of the behaviour). Combined data suggested that interventions that included social norms components were associated with an improvement in health worker behaviour of 0.08 standardised mean differences (95% confidence interval 0.07 to 0.10 standardised mean differences) (n = 100 comparisons), and an improvement in patient outcomes of 0.17 standardised mean differences (95% confidence interval 0.14 to 0.20) (n = 14), on average. Heterogeneity was high, with an overall I 2 of 85.4% (primary) and 91.5% (secondary). Network meta-analysis suggested that three types of social norms intervention were most effective, on average, compared with control: credible source (0.30 standardised mean differences, 95% confidence interval 0.13 to 0.47); social comparison combined with social reward (0.39 standardised mean differences, 95% confidence interval 0.15 to 0.64); and social comparison combined with prompts and cues (0.33 standardised mean differences, 95% confidence interval 0.22 to 0.44).

Limitations

The large number of studies prevented us from requesting additional information from authors. The trials varied in design, context and setting, and we combined different types of outcome to provide an overall summary of evidence, resulting in a very heterogeneous review.

Conclusions

Social norms interventions are an effective method of changing clinical behaviour in a variety of health service contexts. Although the overall result was modest and very variable, there is the potential for social norms interventions to be scaled up to target the behaviour of a large population of health workers and resulting patient outcomes.

Future work

Development of optimised credible source and social comparison behaviour change interventions, including qualitative research on acceptability and feasibility.

Study registration

This study is registered as PROSPERO CRD42016045718.

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. 8, No. 41. See the NIHR Journals Library website for further project information.

Tackling the outcome bias related to the effectiveness of antibiotics against the common cold: results of a randomized controlled trial applying the Solomon four-group design

In recent years, antimicrobial resistance (AMR) has become an international public health priority. In the area of human medicine, the mis- and overuse of antibiotics is an important contributor to the development of AMR. Such a non-prudent use of antibiotics is especially prevalent in the treatment of viral infections such as the common cold. The present study aims to address the misconception, also known as outcome bias, that antibiotics may be an effective treatment against the common cold by providing a "debiasing" risk communication intervention. It aims at conveying the non-existence of a cause-effect relationship between antibiotics and the reduction of cold-related symptoms through a visual aid and simple explanatory text. A Solomon four-group design was employed to test for within- and between-subjects effects of the intervention as well as potential sensitization effects of the repeated measurement. A total of 311 participants residing in Germany were randomly assigned to receiving (1) a pretest, the debiasing intervention and post-test (2), a pretest, a control stimulus and post-test (3), the debiasing intervention and post-test, or (4) the post-test only. Outcome measures included knowledge about the effectiveness of antibiotics, the attitude toward using it as treatment against the common cold and the evaluation of a scenario describing an irresponsible use of antibiotics. Within-subjects comparisons found that participants receiving the pre- and post-test and intervention showed improved knowledge (t(77) = -2.53, p = .014), attitude (t(77) = -2.09, p = .040), and evaluation measures (t(77) = -2.23, p = .028). The pretest might, however, have caused a sensitization of participants for knowledge-related questions (t(77) = 2.207, p = .029). Between-subjects comparisons found differences in knowledge levels between the post-test only group and both groups receiving the intervention (F(3, 307) = 5.63, p = .001, η2p = .05]. There were no differences between the intervention and control groups with regard to attitude and evaluation of the scenario. While the risk communication intervention led to an increase in knowledge, the outcomes related to attitude and evaluation of a scenario were only affected positively in one group. Therefore, it seems that communication interventions based on visual aids are a simple method to promote the understanding of the true relationship between antibiotic treatment and the decrease of cold-related symptoms. Variables such as attitude and evaluation of a scenario presenting the irresponsible use of antibiotics require, however, additional interventions facilitating a translation of accurate understanding into respective attitudes and judgments.

FDA collaboration to improve safe use of fluoroquinolone antibiotics: an ex post facto matched control study of targeted short-form messaging and online education served to high prescribers

Objective:

This ex post facto matched control study was conducted to evaluate the effect of targeted short-form messages or continuing medical education (CME) on fluoroquinolone prescribing among high prescribers.

Methods:

A total of 11,774 Medscape healthcare provider (HCP) members prescribing high volumes of fluoroquinolones were randomized into three segments to receive one of three unique targeted short-form messages, each delivered via email, web alerts, and mobile alerts. Some HCPs receiving targeted short-form messages also participated in CME on fluoroquinolone prescribing. A fourth segment of HCPs participated in CME only. Test HCPs were matched to third-party-provider prescriber data to identify control HCPs. We used prescriber data to determine new prescription volume; percentage (%) of HCPs with reduced prescribing; new prescription volume for acute bacterial sinusitis (ABS), uncomplicated urinary tract infection (uUTI), and acute bacterial exacerbations of chronic bronchitis in those with chronic obstructive pulmonary disease (ABECB-COPD). Open rates for emailed targeted short-form messages were also measured.

Results:

Targeted short-form messages and CME each resulted in significant new prescription volume reduction versus control. Combining targeted short-form messages with CME yielded the greatest percentage of test HCPs with reduced prescribing (80.1%) versus controls (76.2%; p<0.0001). New prescription volume decreased significantly for uUTI and ABS following exposure to targeted short-form messages, CME, or both. Targeted short-form messages containing comparative prescribing information with or without clinical context were opened at slightly higher rates (10.8% and 10.6%, respectively) than targeted short-form messages containing clinical context alone (9.1%).

Conclusions:

Targeted short-form messages and CME, alone and in combination, are associated with reduced oral fluoroquinolone prescribing among high prescribers.

The role of education in antimicrobial stewardship

The role of antimicrobial stewardship programmes (ASPs) has expanded in health systems. ASP interventions often contain an educational component; however, current guidelines suggest that educational interventions should not be used alone but to support other stewardship interventions. Such interventions are most commonly directed towards prescribers (often general practice physicians) with few studies offering education towards other healthcare providers such as pharmacists, nurses, or even members of the stewardship team. Educational interventions are offered most frequently, but not exclusively, with concomitant stewardship interventions such as prospective audit and feedback. Such strategies appear to positively impact prescribing behaviours, but it is not possible to isolate the effect of education from other interventions. Common educational methods include one-time seminars and online e-learning modules, but unique strategies such as social media platforms, educational video games and problem-based learning modules have also been employed. Education directed towards patients often occurs in conjunction with education of local prescribers and wider community-based efforts to impact prescribing. Such studies evaluating patient education often include passive educational leaflets and focus most often on appropriate treatment of upper respiratory tract infections. Educational interventions appear to be an integral component of other interventions of ASPs; however, there is a paucity of evidence to support use as a stand-alone intervention outside of regional public health interventions. Future studies should focus on efficacy of educational interventions including providing education to non-prescribers and disease states beyond upper respiratory tract infections to demonstrate a broader role for education in ASP activities.

Posters Have Limited Utility in Conveying a Message of Antimicrobial Stewardship to Pet Owners

Pet owners frequently administer antimicrobials to their pets and therefore have an important role to play in promoting antimicrobial stewardship in veterinary medicine. However, best methods of educating pet owners about antimicrobial stewardship have yet to be defined. While visual materials such as brochures and posters are often used in health promotion campaigns, their effectiveness in veterinary medicine is unknown. The objective of this study was to determine whether pet owners noticed and retained the message of a poster with an antimicrobial stewardship message placed in veterinary clinic exam rooms. A total of 111 pet owners from five veterinary clinics (three general practices, two low-cost clinics) in the greater Philadelphia area participated in the study. Participants completed a survey asking whether they noticed the poster and if they could paraphrase its message. In a follow-up survey, an antibiotic knowledge score was calculated from answers to questions assessing their knowledge of the poster message. Baseline knowledge was assessed by asking participants to define antibiotic resistance. At the end of the study, veterinarians at participating clinics were interviewed about their experiences with the poster. Only 51 (46.4%) participants noticed the poster, and only 11 (9.9%) could partially or completely reproduce its message. No demographic or clinic-level factors were significantly associated with noticing the poster or recalling its message. Antibiotic knowledge scores were highly correlated (ρ = 0.87, p < 0.001) with baseline knowledge and not affected by viewing the poster (p = 0.955). Veterinarians expressed skepticism that the poster was effective in conveying a message of judicious antibiotic use to clients and noted no difference in the frequency with which they discussed antibiotic resistance or felt pressured to prescribe antibiotics by their clients. Posters alone will likely have limited impact in conveying a message of judicious antibiotic use to pet owners. However, they might be useful as part of an active, multi-modal education strategy, especially if complemented by veterinarian actions.

BundlED Up: A Narrative Review of Antimicrobial Stewardship Initiatives and Bundles in the Emergency Department

Antimicrobial stewardship (ASP) is becoming an increasingly high priority worldwide, yet the emergency department (ED) is an area where stewardship is often neglected. Implementing care bundles, guidelines, and protocols appears to be a rational strategy for ED stewardship given the inherently dynamic and hectic environment of care. Multiple questions still exist such as whether to target certain disease states, optimal implementation of ASP interventions in the ED, and the benefit of unique ED-specific guidelines and protocols. A narrative review was performed on interventions, guidelines, and bundles implemented in the ED setting, in an effort to improve ASP or management of infectious diseases. This review is meant to serve as a framework for the reader to implement these practices at their own institution. We examined various studies related to ASP interventions or care bundles in the ED which included: CNS infections (one study), skin and soft-tissue infections (one study), respiratory infections (four studies), urinary tract infections and sexually transmitted infections (eight studies), sepsis (two studies), culture follow-up programs (four studies), and stewardship in general or multiple infection types (five studies). The interventions in this review were diverse, yet the majority showed a benefit in clinical outcomes or a decrease in antimicrobial use. Care bundles, guidelines, and antimicrobial stewardship interventions can streamline care and improve the management of common infectious diseases seen in the ED.

Communication interventions to promote the public's awareness of antibiotics: a systematic review

Background

Inappropriate antibiotic use is implicated in antibiotic resistance and resultant morbidity and mortality. Overuse is particularly prevalent for outpatient respiratory infections, and perceived patient expectations likely contribute. Thus, various educational programs have been implemented to educate the public.

Methods

We systematically identified public-directed interventions to promote antibiotic awareness in the United States. PubMed, Google Scholar, Embase, CINAHL, and Scopus were queried for articles published from January 1996 through January 2016. Two investigators independently assessed titles and abstracts of retrieved articles for subsequent full-text review. References of selected articles and three review articles were likewise screened for inclusion. Identified educational interventions were coded for target audience, content, distribution site, communication method, and major outcomes.

Results

Our search yielded 1,106 articles; 34 met inclusion criteria. Due to overlap in interventions studied, 29 distinct educational interventions were identified. Messages were primarily delivered in outpatient clinics (N = 24, 83%) and community sites (N = 12, 41%). The majority included clinician education. Antibiotic prescription rates were assessed for 22 interventions (76%). Patient knowledge, attitudes, and beliefs (KAB) were assessed for 10 interventions (34%). Similar rates of success between antibiotic prescription rates and patient KAB were reported (73 and 70%, respectively). Patient interventions that did not include clinician education were successful to increase KAB but were not shown to decrease antibiotic prescribing. Three interventions targeted reductions in Streptococcus pneumoniae resistance; none were successful.

Conclusions

Messaging programs varied in their designs, and many were multifaceted in their approach. These interventions can change patient perspectives regarding antibiotic use, though it is unclear if clinician education is also necessary to reduce antibiotic prescribing. Further investigations are needed to determine the relative influence of interventions focusing on patients and physicians and to determine whether these changes can influence rates of antibiotic resistance long-term.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7258-3) contains supplementary material, which is available to authorized users.

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.

Examining Workflow in a Pediatric Emergency Department to Develop a Clinical Decision Support for an Antimicrobial Stewardship Program

BACKGROUND

Clinical decision support (CDS) embedded into the electronic health record (EHR), is a potentially powerful tool for institution of antimicrobial stewardship programs (ASPs) in emergency departments (EDs). However, design and implementation of CDS systems should be informed by the existing workflow to ensure its congruence with ED practice, which is characterized by erratic workflow, intermittent computer interactions, and variable timing of antibiotic prescription.

OBJECTIVE

This article aims to characterize ED workflow for four provider types, to guide future design and implementation of an ED-based ASP using the EHR.

METHODS

Workflow was systematically examined in a single, tertiary-care academic children's hospital ED. Clinicians with four roles (attending, nurse practitioner, physician assistant, resident) were observed over a 3-month period using a tablet computer-based data collection tool. Structural observations were recorded by investigators, and classified using a predetermined set of activities. Clinicians were queried regarding timing of diagnosis and disposition decision points.

RESULTS

A total of 23 providers were observed for 90 hours. Sixty-four different activities were captured for a total of 6,060 times. Among these activities, nine were conducted at different frequency or time allocation across four roles. Moreover, we identified differences in sequential patterns across roles. Decision points, whereby clinicians then proceeded with treatment, were identified 127 times. The most common decision points identified were: (1) after/during examining or talking to patient or relative; (2) after talking to a specialist; and (3) after diagnostic test/image was resulted and discussed with patient/family.

CONCLUSION

The design and implementation of CDS for ASP should support clinicians in various provider roles, despite having different workflow patterns. The clinicians make their decisions about treatment at different points of overall care delivery practice; likewise, the CDS should also support decisions at different points of care.

Review of implementation strategies to change healthcare provider behaviour in the emergency department

OBJECTIVES

Advances in emergency medicine research can be slow to make their way into clinical care, and implementing a new evidence-based intervention can be challenging in the emergency department. The Canadian Association of Emergency Physicians (CAEP) Knowledge Translation Symposium working group set out to produce recommendations for best practice in the implementation of a new science in Canadian emergency departments.

METHODS

A systematic review of implementation strategies to change health care provider behaviour in the emergency department was conducted simultaneously with a national survey of emergency physician experience. We summarized our findings into a list of draft recommendations that were presented at the national CAEP Conference 2017 and further refined based on feedback through social media strategies.

RESULTS

We produced 10 recommendations for implementing new evidence-based interventions in the emergency department, which cover identifying a practice gap, evaluating the evidence, planning the intervention strategy, monitoring, providing feedback during implementation, and desired qualities of future implementation research.

CONCLUSIONS

We present recommendations to guide future emergency department implementation initiatives. There is a need for robust and well-designed implementation research to guide future emergency department implementation initiatives.

Interventions to improve antimicrobial prescribing of doctors in training (IMPACT): a realist review

Background

Interventions to improve the antimicrobial prescribing practices of doctors have been implemented widely to curtail the emergence and spread of antimicrobial resistance, but have been met with varying levels of success.

Objectives

This study aimed to generate an in-depth understanding of how antimicrobial prescribing interventions ‘work’ (or do not work) for doctors in training by taking into account the wider context in which prescribing decisions are enacted.

Design

The review followed a realist approach to evidence synthesis, which uses an interpretive, theory-driven analysis of qualitative, quantitative and mixed-methods data from relevant studies.

Setting

Primary and secondary care.

Participants

Not applicable.

Interventions

Studies related to antimicrobial prescribing for doctors in training.

Main outcome measures

Not applicable.

Data sources

EMBASE (via Ovid), MEDLINE (via Ovid), MEDLINE In-Process & Other Non-Indexed Citations (via Ovid), PsycINFO (via Ovid), Web of Science core collection limited to Science Citation Index Expanded (SCIE) and Conference Proceedings Citation Index – Science (CPCI-S) (via Thomson Reuters), Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, the Health Technology Assessment (HTA) database (all via The Cochrane Library), Applied Social Sciences Index and Abstracts (ASSIA) (via ProQuest), Google Scholar (Google Inc., Mountain View, CA, USA) and expert recommendations.

Review methods

Clearly bounded searches of electronic databases were supplemented by citation tracking and grey literature. Following quality standards for realist reviews, the retrieved articles were systematically screened and iteratively analysed to develop theoretically driven explanations. A programme theory was produced with input from a stakeholder group consisting of practitioners and patient representatives.

Results

A total of 131 articles were included. The overarching programme theory developed from the analysis of these articles explains how and why doctors in training decide to passively comply with or actively follow (1) seniors’ prescribing habits, (2) the way seniors take into account prescribing aids and seek the views of other health professionals and (3) the way seniors negotiate patient expectations. The programme theory also explains what drives willingness or reluctance to ask questions about antimicrobial prescribing or to challenge the decisions made by seniors. The review outlines how these outcomes result from complex inter-relationships between the contexts of practice doctors in training are embedded in (hierarchical relationships, powerful prescribing norms, unclear roles and responsibilities, implicit expectations about knowledge levels and application in practice) and the mechanisms triggered in these contexts (fear of criticism and individual responsibility, reputation management, position in the clinical team and appearing competent). Drawing on these findings, we set out explicit recommendations for optimal tailoring, design and implementation of antimicrobial prescribing interventions targeted at doctors in training.

Limitations

Most articles included in the review discussed hospital-based, rather than primary, care. In cases when few data were available to fully capture all the nuances between context, mechanisms and outcomes, we have been explicit about the strength of our arguments.

Conclusions

This review contributes to our understanding of how antimicrobial prescribing interventions for doctors in training can be better embedded in the hierarchical and interprofessional dynamics of different health-care settings.

Future work

More work is required to understand how interprofessional support for doctors in training can contribute to appropriate prescribing in the context of hierarchical dynamics.

Study registration

This study is registered as PROSPERO CRD42015017802.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Assessments of Opportunities to Improve Antibiotic Prescribing in an Emergency Department: A Period Prevalence Survey

Introduction

Approximately 30% of all outpatient antimicrobials are inappropriately prescribed. Currently, antimicrobial prescribing patterns in emergency departments (ED) are not well described. Determining inappropriate antimicrobial prescribing patterns and opportunities for interventions by antimicrobial stewardship programs (ASP) are needed.

Methods

A retrospective chart review was performed among a random sample of non-admitted, adult patients who received an antimicrobial prescription in the ED from January 1 to December 31, 2015. Appropriateness was measured using the Medication Appropriateness Index, and was based on provider adherence to local guidelines. Additional information collected included patient characteristics, initial diagnoses, and other chronic medication use.

Results

Of 1579 ED antibiotic prescriptions in 2015, we reviewed a total of 159 (10.1%) prescription records. The most frequently prescribed antimicrobial classes included penicillins (22.6%), macrolides (20.8%), cephalosporins (17.6%), and fluoroquinolones (17.0%). The most common indications for antibiotics were bronchitis or upper respiratory tract infection (URTI) (35.1%), followed by skin and soft tissue infection (SSTI) (25.0%), both of which were the most common reason for unnecessary prescribing (28.9% of bronchitis/URTIs, 25.6% of SSTIs). Of the antimicrobial prescriptions reviewed, 39% met criteria for inappropriateness. Among 78 prescriptions with a consensus on appropriate indications, 13.8% had inappropriate dosing, duration, or expense.

Conclusion

Consistent with national outpatient prescribing, inappropriate antibiotic prescribing in the ED occurred in 39% of cases with the highest rates observed among patients with bronchitis, URTI, and SSTI. Antimicrobial stewardship programs may benefit by focusing on initiatives for these conditions among ED patients. Moreover, creation of local guideline pocketbooks for these and other conditions may serve to improve prescribing practices and meet the Core Elements of Outpatient Stewardship recommended by the Centers for Disease Control and Prevention.

Design and rationale of the Procalcitonin Antibiotic Consensus Trial (ProACT), a multicenter randomized trial of procalcitonin antibiotic guidance in lower respiratory tract infection

BACKGROUND

Overuse of antibiotics is a major public health problem, contributing to growing antibiotic resistance. Procalcitonin has been reported to be commonly elevated in bacterial, but not viral infection. Multiple European trials found procalcitonin-guided care reduced antibiotic use in lower respiratory tract infection, with no apparent harm. However, applicability to US practice is limited due to trial design features impractical in the US, between-country differences, and residual safety concerns.

METHODS

The Procalcitonin Antibiotic Consensus Trial (ProACT) is a multicenter randomized trial to determine the impact of a procalcitonin antibiotic prescribing guideline, implemented with basic reproducible strategies, in US patients with lower respiratory tract infection.

DISCUSSION

We describe the trial methods using the Consolidated Standards of Reporting Trials (CONSORT) framework, and the rationale for key design decisions, including choice of eligibility criteria, choice of control arm, and approach to guideline implementation.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02130986 . Registered May 1, 2014.

Implementation of effective practices in health facilities: a systematic review of cluster randomised trials

Background

The capacity for health systems to support the translation of research in to clinical practice may be limited. The cluster randomised controlled trial (cluster RCT) design is often employed in evaluating the effectiveness of implementation of evidence-based practices. We aimed to systematically review available evidence to identify and evaluate the components in the implementation process at the facility level using cluster RCT designs.

Methods

All cluster RCTs where the healthcare facility was the unit of randomisation, published or written from 1990 to 2014, were assessed. Included studies were analysed for the components of implementation interventions employed in each. Through iterative mapping and analysis, we synthesised a master list of components used and summarised the effects of different combinations of interventions on practices.

Results

Forty-six studies met the inclusion criteria and covered the specialty groups of obstetrics and gynaecology (n=9), paediatrics and neonatology (n=4), intensive care (n=4), internal medicine (n=20), and anaesthetics and surgery (n=3). Six studies included interventions that were delivered across specialties. Nine components of multifaceted implementation interventions were identified: leadership, barrier identification, tailoring to the context, patient involvement, communication, education, supportive supervision, provision of resources, and audit and feedback. The four main components that were most commonly used were education (n=42, 91%), audit and feedback (n=26, 57%), provision of resources (n=23, 50%) and leadership (n=21, 46%).

Conclusions

Future implementation research should focus on better reporting of multifaceted approaches, incorporating sets of components that facilitate the translation of research into practice, and should employ rigorous monitoring and evaluation.

Impact of an antimicrobial stewardship programme to optimize antimicrobial use for outpatients at an emergency department

BACKGROUND

Antimicrobial stewardship programmes (ASPs) have been effective in optimizing antibiotic use for inpatients. However, an emergency department's fast-paced clinical setting can be challenging for a successful ASP.

AIM

In April 2015, an ASP was implemented in our emergency department and we aimed to determine its impact on antimicrobial use for outpatients.

METHODS

This was a single-centre study comparing the quality of antibiotic prescriptions between a one-year period before ASP implementation (November 2012 to October 2013) and a one-year period after its implementation (June 2015 to May 2016). For each period, antimicrobial prescriptions for all adult outpatients (hospitalized for <24h) were evaluated by an infectious disease specialist and an emergency department physician to assess compliance with local prescribing guidelines. Inappropriate prescriptions were then classified.

FINDINGS

Before and after ASP, 34,671 and 35,925 consultations were registered at our emergency department, of which 25,470 and 26,208 were outpatients. Antimicrobials were prescribed in 769 (3.0%) and 580 (2.2%) consultations, respectively (P < 0.0001). There were 484 (62.9%) and 271 (46.7%) (P < 0.0001) instances of non-compliance with guidelines before and after ASP implementation. Non-compliance included unnecessary antimicrobial prescriptions, 197 (25.6%) vs 101 (17.4%) (P<0.0005); inappropriate spectrum, 108 (14.0%) vs 54 (9.3%) (P=0.008); excessive treatment duration, 87 (11.3%) vs 53 (9.1%) (P>0.05); and inappropriate choices, 11 (1.4%) vs 15 (2.6%) (P>0.05).

CONCLUSION

The implementation of an ASP markedly decreased the number of unnecessary antimicrobial prescriptions, but had little impact on most other aspects of inappropriate prescribing.

A Systematic Review of Antimicrobial Stewardship Interventions in the Emergency Department

BACKGROUND/OBJECTIVE

To improve antimicrobial utilization, development and implementation of antimicrobial stewardship programs in the emergency department (ED) has been recommended. The primary objective of this review was to characterize antimicrobial stewardship (AMS) in the ED and to identify interventions that improve patient outcomes or process of care and/or reduce consequences of antimicrobial use.

METHODS

This study was completed as a systematic review. The following databases were searched from inception through November, 2016: MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, Scopus, and Web of Science. Randomized controlled trials, nonrandomized controlled trials, controlled and uncontrolled before-and-after studies, interrupted time series studies, and repeated-measures studies evaluating AMS interventions in the ED were included in the review. Studies published in languages other than English were excluded.

RESULTS

A total of 43 studies meeting inclusion criteria were identified from our search. Patient or provider education and guideline or clinical pathway implementation were the most commonly reported interventions. Few studies reported on audit and feedback, and no study evaluated preauthorization. Impact of interventions showed variable results. Where identified, benefits of AMS interventions primarily included improvement in delivery of care or a decrease in antimicrobial utilization; however, most studies were rated as having unclear or high risk of bias.

CONCLUSION

AMS interventions in the ED may improve patient care. However, the optimal combination of interventions is unclear. Additional studies with more rigorous design evaluating core components of AMS programs, including prospective audit and feedback are needed.

Impact of a multifaceted antimicrobial stewardship program: A front-line ownership driven quality improvement project in a large urban emergency department

BACKGROUND

Antibiotic overuse has promoted growing rates of antimicrobial resistance and secondary antibiotic-associated infections such as Clostridium difficile (C. difficile). Antimicrobial stewardship programs (ASPs) are effective in reducing antimicrobial use in the inpatient setting; however, the unique environment of the emergency department (ED) lends itself to challenges for successful implementation. Front-line ownership (FLO) methodology has been shown to be a potentially effective strategy for the implementation of inpatient ASPs through an iterative multi-pronged approach driven by front-line providers.

OBJECTIVE

To determine whether a FLO approach to antimicrobial stewardship in the ED can alter antimicrobial usage.

METHODS

Interventions were driven by ED physicians and facilitated by Infectious Diseases Division physicians from the hospital's ASP using FLO principles. Measured end points included antibiotic usage in the ED as measured by defined daily doses, and rates of urine culture sent from the ED.

RESULTS

There was a step-wise significant reduction in the use of azithromycin (p=0.006), ceftriaxone (p=0.045), ciprofloxacin (p=0.034), and moxifloxacin (p=0.008). There was also a significant reduction in rates of urine cultures (p<0.001) by 2.26 urine cultures per 100 ED patient visits.

CONCLUSIONS

FLO offers a promising approach to successful implementation of an ASP in the ED. Future studies would be important to evaluate the generalizability of the FLO approach to ASP development in other EDs and to determine strategies to improve the sustainability of reductions in antimicrobial use.

Strategies to enhance rational use of antibiotics in hospital: a guideline by the German Society for Infectious Diseases

Introduction

In the time of increasing resistance and paucity of new drug development there is a growing need for strategies to enhance rational use of antibiotics in German and Austrian hospitals. An evidence-based guideline on recommendations for implementation of antibiotic stewardship (ABS) programmes was developed by the German Society for Infectious Diseases in association with the following societies, associations and institutions: German Society of Hospital Pharmacists, German Society for Hygiene and Microbiology, Paul Ehrlich Society for Chemotherapy, The Austrian Association of Hospital Pharmacists, Austrian Society for Infectious Diseases and Tropical Medicine, Austrian Society for Antimicrobial Chemotherapy, Robert Koch Institute.

Materials and methods

A structured literature research was performed in the databases EMBASE, BIOSIS, MEDLINE and The Cochrane Library from January 2006 to November 2010 with an update to April 2012 (MEDLINE and The Cochrane Library). The grading of recommendations in relation to their evidence is according to the AWMF Guidance Manual and Rules for Guideline Development.

Conclusion

The guideline provides the grounds for rational use of antibiotics in hospital to counteract antimicrobial resistance and to improve the quality of care of patients with infections by maximising clinical outcomes while minimising toxicity. Requirements for a successful implementation of ABS programmes as well as core and supplemental ABS strategies are outlined. The German version of the guideline was published by the German Association of the Scientific Medical Societies (AWMF) in December 2013.

Current State of Antimicrobial Stewardship in Children's Hospital Emergency Departments

BACKGROUND Antimicrobial stewardship programs (ASPs) effectively optimize antibiotic use for inpatients; however, the extent of emergency department (ED) involvement in ASPs has not been described. OBJECTIVE To determine current ED involvement in children's hospital ASPs and to assess beliefs and preferred methods of implementation for ED-based ASPs. METHODS A cross-sectional survey of 37 children's hospitals participating in the Sharing Antimicrobial Resistance Practices collaboration was conducted. Surveys were distributed to ASP leaders and ED medical directors at each institution. Items assessed included beliefs regarding ED antibiotic prescribing, ED prescribing resources, ASP methods used in the ED such as clinical decision support and clinical care guidelines, ED participation in ASP activities, and preferred methods for ED-based ASP implementation. RESULTS A total of 36 ASP leaders (97.3%) and 32 ED directors (86.5%) responded; the overall response rate was 91.9%. Most ASP leaders (97.8%) and ED directors (93.7%) agreed that creation of ED-based ASPs was necessary. ED resources for antibiotic prescribing were obtained via the Internet or electronic health records (EHRs) for 29 hospitals (81.3%). The main ASP activities for the ED included production of antibiograms (77.8%) and creation of clinical care guidelines for pneumonia (83.3%). The ED was represented on 3 hospital ASP committees (8.3%). No hospital ASPs actively monitored outpatient ED prescribing. Most ASP leaders (77.8%) and ED directors (81.3%) preferred implementation of ED-based ASPs using clinical decision support integrated into the EHR. CONCLUSIONS Although ED involvement in ASPs is limited, both ASP and ED leaders believe that ED-based ASPs are necessary. Many children's hospitals have the capability to implement ED-based ASPs via the preferred method: EHR clinical decision support. Infect Control Hosp Epidemiol 2017;38:469-475.

Written information for patients (or parents of child patients) to reduce the use of antibiotics for acute upper respiratory tract infections in primary care

BACKGROUND

Acute upper respiratory tract infections (URTIs) are frequently managed in primary care settings. Although many are viral, and there is an increasing problem with antibiotic resistance, antibiotics continue to be prescribed for URTIs. Written patient information may be a simple way to reduce antibiotic use for acute URTIs.

OBJECTIVES

To assess if written information for patients (or parents of child patients) reduces the use of antibiotics for acute URTIs in primary care.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, LILACS, Web of Science, clinical trials.gov, and the World Health Organization (WHO) trials registry up to July 2016 without language or publication restrictions.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) involving patients (or parents of child patients) with acute URTIs, that compared written patient information delivered immediately before or during prescribing, with no information. RCTs needed to have measured our primary outcome (antibiotic use) to be included.

DATA COLLECTION AND ANALYSIS

Two review authors screened studies, extracted data, and assessed study quality. We could not meta-analyse included studies due to significant methodological and statistical heterogeneity; we summarised the data narratively.

MAIN RESULTS

Two RCTs met our inclusion criteria, involving a total of 827 participants. Both studies only recruited children with acute URTIs (adults were not involved in either study): 558 children from 61 general practices in England and Wales; and 269 primary care doctors who provided data on 33,792 patient-doctor consultations in Kentucky, USA. The UK study had a high risk of bias due to lack of blinding and the US cluster-randomised study had a high risk of bias because the methods to allocate participants to treatment groups was not clear, and there was evidence of baseline imbalance.In both studies, clinicians provided written information to parents of child patients during primary care consultations: one trained general practitioners (GPs) to discuss an eight-page booklet with parents; the other conducted a factorial trial with two comparison groups (written information compared to usual care and written information plus prescribing feedback to clinicians compared to prescribing feedback alone). Doctors in the written information arms received 25 copies of two-page government-sponsored pamphlets to distribute to parents.Compared to usual care, we found moderate quality evidence (one study) that written information significantly reduced the number of antibiotics used by patients (RR 0.53, 95% CI 0.35 to 0.80; absolute risk reduction (ARR) 20% (22% versus 42%)) and had no significant effect on reconsultation rates (RR 0.79, 95% CI 0.47 to 1.32), or parent satisfaction with consultation (RR 0.95, 95% CI 0.87 to 1.03). Low quality evidence (two studies) demonstrated that written information also reduced antibiotics prescribed by clinicians (RR 0.47, 95% CI 0.28 to 0.78; ARR 21% (20% versus 41%); and RR 0.84, 95% CI 0.81 to 0.86; 9% ARR (45% versus 54%)). Neither study measured resolution of symptoms, patient knowledge about antibiotics for acute URTIs, or complications for this comparison.Compared to prescribing feedback, we found low quality evidence that written information plus prescribing feedback significantly increased the number of antibiotics prescribed by clinicians (RR 1.13, 95% CI 1.09 to 1.17; absolute risk increase 6% (50% versus 44%)). Neither study measured reconsultation rate, resolution of symptoms, patient knowledge about antibiotics for acute URTIs, patient satisfaction with consultation or complications for this comparison.

AUTHORS' CONCLUSIONS

Compared to usual care, moderate quality evidence from one study showed that trained GPs providing written information to parents of children with acute URTIs in primary care can reduce the number of antibiotics used by patients without any negative impact on reconsultation rates or parental satisfaction with consultation. Low quality evidence from two studies shows that, compared to usual care, GPs prescribe fewer antibiotics for acute URTIs but prescribe more antibiotics when written information is provided alongside prescribing feedback (compared to prescribing feedback alone). There was no evidence addressing resolution of patients' symptoms, patient knowledge about antibiotics for acute URTIs, or frequency of complications.To fill evidence gaps, future studies should consider testing written information on antibiotic use for adults with acute URTIs in high- and low-income settings provided without clinician training and presented in different formats (such as electronic). Future study designs should endeavour to ensure blinded outcome assessors. Study aims should include measurement of the effect of written information on the number of antibiotics used by patients and prescribed by clinicians, patient satisfaction, reconsultation, patients' knowledge about antibiotics, resolution of symptoms, and complications.

Core Elements of Outpatient Antibiotic Stewardship

The Core Elements of Outpatient Antibiotic Stewardship provides a framework for antibiotic stewardship for outpatient clinicians and facilities that routinely provide antibiotic treatment. This report augments existing guidance for other clinical settings. In 2014 and 2015, respectively, CDC released the Core Elements of Hospital Antibiotic Stewardship Programs and the Core Elements of Antibiotic Stewardship for Nursing Homes. Antibiotic stewardship is the effort to measure and improve how antibiotics are prescribed by clinicians and used by patients. Improving antibiotic prescribing involves implementing effective strategies to modify prescribing practices to align them with evidence-based recommendations for diagnosis and management. The four core elements of outpatient antibiotic stewardship are commitment, action for policy and practice, tracking and reporting, and education and expertise. Outpatient clinicians and facility leaders can commit to improving antibiotic prescribing and take action by implementing at least one policy or practice aimed at improving antibiotic prescribing practices. Clinicians and leaders of outpatient clinics and health care systems can track antibiotic prescribing practices and regularly report these data back to clinicians. Clinicians can provide educational resources to patients and families on appropriate antibiotic use. Finally, leaders of outpatient clinics and health systems can provide clinicians with education aimed at improving antibiotic prescribing and with access to persons with expertise in antibiotic stewardship. Establishing effective antibiotic stewardship interventions can protect patients and improve clinical outcomes in outpatient health care settings.

Behavioral interventions to reduce inappropriate antibiotic prescribing: a randomized pilot trial

Background

Clinicians frequently prescribe antibiotics inappropriately for acute respiratory infections (ARIs). Our objective was to test information technology-enabled behavioral interventions to reduce inappropriate antibiotic prescribing for ARIs in a randomized controlled pilot test trial.

Methods

Primary care clinicians were randomized in a 2 × 2 × 2 factorial experiment with 3 interventions: 1) Accountable Justifications; 2) Suggested Alternatives; and 3) Peer Comparison. Beforehand, participants completed an educational module. Measures included: rates of antibiotic prescribing for: non-antibiotic-appropriate ARI diagnoses, acute sinusitis/pharyngitis, all other diagnoses/symptoms of respiratory infection, and all three ARI categories combined.

Results

We examined 3,276 visits in the pre-intervention year and 3,099 in the intervention year. The antibiotic prescribing rate fell for non-antibiotic-appropriate ARIs (24.7 % in the pre-intervention year to 5.2 % in the intervention year); sinusitis/pharyngitis (50.3 to 44.7 %); all other diagnoses/symptoms of respiratory infection (40.2 to 25.3 %); and all categories combined (38.7 to 24.2 %; all p < 0.001). There were no significant relationships between any intervention and antibiotic prescribing for non-antibiotic-appropriate ARI diagnoses or sinusitis/pharyngitis. Suggested Alternatives was associated with reduced antibiotic prescribing for other diagnoses or symptoms of respiratory infection (odds ratio [OR], 0.62; 95 % confidence interval [CI], 0.44–0.89) and for all ARI categories combined (OR, 0.72; 95 % CI, 0.54–0.96). Peer Comparison was associated with reduced prescribing for all ARI categories combined (OR, 0.73; 95 % CI, 0.53–0.995).

Conclusions

We observed large reductions in antibiotic prescribing regardless of whether or not study participants received an intervention, suggesting an overriding Hawthorne effect or possibly clinician-to-clinician contamination. Low baseline inappropriate prescribing may have led to floor effects.

Trial Registration

ClinicalTrials.gov: NCT01454960.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-016-1715-8) contains supplementary material, which is available to authorized users.

Interventions Aimed at Reducing Use of Low-Value Health Services: A Systematic Review

The effectiveness of different types of interventions to reduce low-value care has been insufficiently summarized to allow for translation to practice. This article systematically reviews the literature on the effectiveness of interventions to reduce low-value care and the quality of those studies. We found that multicomponent interventions addressing both patient and clinician roles in overuse have the greatest potential to reduce low-value care. Clinical decision support and performance feedback are promising strategies with a solid evidence base, and provider education yields changes by itself and when paired with other strategies. Further research is needed on the effectiveness of pay-for-performance, insurer restrictions, and risk-sharing contracts to reduce use of low-value care. While the literature reveals important evidence on strategies used to reduce low-value care, meaningful gaps persist. More experimentation, paired with rigorous evaluation and publication, is needed.

The frequency of influenza and bacterial coinfection: a systematic review and meta-analysis

Aim

Coinfecting bacterial pathogens are a major cause of morbidity and mortality in influenza. However, there remains a paucity of literature on the magnitude of coinfection in influenza patients.

Method

A systematic search of MeSH, Cochrane Library, Web of Science, SCOPUS, EMBASE, and PubMed was performed. Studies of humans in which all individuals had laboratory confirmed influenza, and all individuals were tested for an array of common bacterial species, met inclusion criteria.

Results

Twenty‐seven studies including 3215 participants met all inclusion criteria. Common etiologies were defined from a subset of eight articles. There was high heterogeneity in the results (I² = 95%), with reported coinfection rates ranging from 2% to 65%. Although only a subset of papers were responsible for observed heterogeneity, subanalyses and meta‐regression analysis found no study characteristic that was significantly associated with coinfection. The most common coinfecting species were Streptococcus pneumoniae and Staphylococcus aureus, which accounted for 35% (95% CI, 14%–56%) and 28% (95% CI, 16%–40%) of infections, respectively; a wide range of other pathogens caused the remaining infections. An assessment of bias suggested that lack of small‐study publications may have biased the results.

Conclusions

The frequency of coinfection in the published studies included in this review suggests that although providers should consider possible bacterial coinfection in all patients hospitalized with influenza, they should not assume all patients are coinfected and be sure to properly treat underlying viral processes. Further, high heterogeneity suggests additional large‐scale studies are needed to better understand the etiology of influenza bacterial coinfection.

Effect of Behavioral Interventions on Inappropriate Antibiotic Prescribing Among Primary Care Practices: A Randomized Clinical Trial

IMPORTANCE

Interventions based on behavioral science might reduce inappropriate antibiotic prescribing.

OBJECTIVE

To assess effects of behavioral interventions and rates of inappropriate (not guideline-concordant) antibiotic prescribing during ambulatory visits for acute respiratory tract infections.

DESIGN, SETTING, AND PARTICIPANTS

Cluster randomized clinical trial conducted among 47 primary care practices in Boston and Los Angeles. Participants were 248 enrolled clinicians randomized to receive 0, 1, 2, or 3 interventions for 18 months. All clinicians received education on antibiotic prescribing guidelines on enrollment. Interventions began between November 1, 2011, and October 1, 2012. Follow-up for the latest-starting sites ended on April 1, 2014. Adult patients with comorbidities and concomitant infections were excluded.

INTERVENTIONS

Three behavioral interventions, implemented alone or in combination: suggested alternatives presented electronic order sets suggesting nonantibiotic treatments; accountable justification prompted clinicians to enter free-text justifications for prescribing antibiotics into patients' electronic health records; peer comparison sent emails to clinicians that compared their antibiotic prescribing rates with those of "top performers" (those with the lowest inappropriate prescribing rates).

MAIN OUTCOMES AND MEASURES

Antibiotic prescribing rates for visits with antibiotic-inappropriate diagnoses (nonspecific upper respiratory tract infections, acute bronchitis, and influenza) from 18 months preintervention to 18 months afterward, adjusting each intervention's effects for co-occurring interventions and preintervention trends, with random effects for practices and clinicians.

RESULTS

There were 14,753 visits (mean patient age, 47 years; 69% women) for antibiotic-inappropriate acute respiratory tract infections during the baseline period and 16,959 visits (mean patient age, 48 years; 67% women) during the intervention period. Mean antibiotic prescribing rates decreased from 24.1% at intervention start to 13.1% at intervention month 18 (absolute difference, -11.0%) for control practices; from 22.1% to 6.1% (absolute difference, -16.0%) for suggested alternatives (difference in differences, -5.0% [95% CI, -7.8% to 0.1%]; P = .66 for differences in trajectories); from 23.2% to 5.2% (absolute difference, -18.1%) for accountable justification (difference in differences, -7.0% [95% CI, -9.1% to -2.9%]; P < .001); and from 19.9% to 3.7% (absolute difference, -16.3%) for peer comparison (difference in differences, -5.2% [95% CI, -6.9% to -1.6%]; P < .001). There were no statistically significant interactions (neither synergy nor interference) between interventions.

CONCLUSIONS AND RELEVANCE

Among primary care practices, the use of accountable justification and peer comparison as behavioral interventions resulted in lower rates of inappropriate antibiotic prescribing for acute respiratory tract infections.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01454947.

Antimicrobial stewardship in outpatient settings: a systematic review

OBJECTIVE

Evaluate the effect of outpatient antimicrobial stewardship programs on prescribing, patient, microbial outcomes, and costs.

DESIGN

Systematic review

METHODS

Search of MEDLINE (2000 through November 2013), Cochrane Library, and reference lists of relevant studies. We included English language studies with patient populations relevant to the United States (eg, infectious conditions, prescription services) evaluating stewardship programs in outpatient settings and reporting outcomes of interest. Data regarding study characteristics and outcomes were extracted and organized by intervention type.

RESULTS

We identified 50 studies eligible for inclusion, with most (29 of 50; 58%) reporting on respiratory tract infections, followed by multiple/unspecified infections (17 of 50; 34%). We found medium-strength evidence that stewardship programs incorporating communication skills training and laboratory testing are associated with reductions in antimicrobial use, and low-strength evidence that other stewardship interventions are associated with improved prescribing. Patient-centered outcomes, which were infrequently reported, were not adversely affected. Medication costs were generally lower with stewardship interventions, but overall program costs were rarely reported. No studies reported microbial outcomes, and data regarding outpatient settings other than primary care clinics are limited.

CONCLUSIONS

Low- to moderate-strength evidence suggests that antimicrobial stewardship programs in outpatient settings improve antimicrobial prescribing without adversely effecting patient outcomes. Effectiveness depends on program type. Most studies were not designed to measure patient or resistance outcomes. Data regarding sustainability and scalability of interventions are limited.

Interventions to improve antimicrobial prescribing of doctors in training: the IMPACT (IMProving Antimicrobial presCribing of doctors in Training) realist review

INTRODUCTION

Antimicrobial resistance has been described as a global crisis-more prudent prescribing is part of the solution. Behaviour change interventions are needed to improve prescribing practice. Presently, the literature documents that context impacts on prescribing decisions, yet insufficient evidence exists to enable researchers and policymakers to determine how local tailoring should take place. Doctors in training are an important group to study, being numerically the largest group of prescribers in UK hospitals. Unfortunately very few interventions specifically targeted this group.

METHODS AND ANALYSIS

Our project aims to understand how interventions to change antimicrobial prescribing behaviours of doctors in training produce their effects. We will recruit a project stakeholder group to advise us throughout. We will synthesise the literature using the realist review approach-a form of theory-driven interpretive systematic review approach often used to make sense of complex interventions. Interventions to improve antimicrobial prescribing behaviours are complex-they are context dependent, have long implementation chains, multiple non-linear interactions, emergence and depend on human agency. Our review will iteratively progress through 5 steps: step 1--Locate existing theories; step 2--Search for evidence; step 3--Article selection; step 4--Extracting and organising data; and step 5--Synthesising the evidence and drawing conclusions. Data analysis will use a realist logic of analysis to describe and explain what works, for whom, in what circumstances, in what respects, how and why to improve antimicrobial prescribing behaviour of doctors in training.

ETHICS AND DISSEMINATION

Ethical approval was not required for our review. Our dissemination strategy will be participatory and involve input from our stakeholder group. Tailored project outputs will be targeted at 3 audiences: (1) doctors in training; (2) clinical supervisors/trainers and medical educators; and (3) policy, decision makers, regulators and royal societies.

Improving emergency physician performance using audit and feedback: a systematic review

BACKGROUND

Audit and feedback can decrease variation and improve the quality of care in a variety of health care settings. There is a growing literature on audit and feedback in the emergency department (ED) setting. Because most studies have been small and not focused on a single clinical process, systematic assessment could determine the effectiveness of audit and feedback interventions in the ED and which specific characteristics improve the quality of emergency care.

OBJECTIVE

The objective of the study is to assess the effect of audit and feedback on emergency physician performance and identify features critical to success.

METHODS

We adhered to the PRISMA statement to conduct a systematic review of the literature from January 1994 to January 2014 related to audit and feedback of physicians in the ED. We searched Medline, EMBASE, PsycINFO, and PubMed databases. We included studies that were conducted in the ED and reported quantitative outcomes with interventions using both audit and feedback. For included studies, 2 reviewers independently assessed methodological quality using the validated Downs and Black checklist for nonrandomized studies. Treatment effect and heterogeneity were to be reported via meta-analysis and the I2 inconsistency index.

RESULTS

The search yielded 4332 articles, all of which underwent title review; 780 abstracts and 131 full-text articles were reviewed. Of these, 24 studies met inclusion criteria with an average Downs and Black score of 15.6 of 30 (range, 6-22). Improved performance was reported in 23 of the 24 studies. Six studies reported sufficient outcome data to conduct summary analysis. Pooled data from studies that included 41,124 patients yielded an average treatment effect among physicians of 36% (SD, 16%) with high heterogeneity (I2=83%).

CONCLUSION

The literature on audit and feedback in the ED reports positive results for interventions across numerous clinical conditions but without standardized reporting sufficient for meta-analysis. Characteristics of audit and feedback interventions that were used in a majority of studies were feedback that targeted errors of omission and that was explicit with measurable instruction and a plan for change delivered in the clinical setting greater than 1 week after the audited performance using a combination of media and types at both the individual and group levels. Future work should use standardized reporting to identify the specific aspects of audit or feedback that drive effectiveness in the ED.

Educational effectiveness, target, and content for prudent antibiotic use

Widespread antimicrobial use and concomitant resistance have led to a significant threat to public health. Because inappropriate use and overuse of antibiotics based on insufficient knowledge are one of the major drivers of antibiotic resistance, education about prudent antibiotic use aimed at both the prescribers and the public is important. This review investigates recent studies on the effect of interventions for promoting prudent antibiotics prescribing. Up to now, most educational efforts have been targeted to medical professionals, and many studies showed that these educational efforts are significantly effective in reducing antibiotic prescribing. Recently, the development of educational programs to reduce antibiotic use is expanding into other groups, such as the adult public and children. The investigation of the contents of educational programs for prescribers and the public demonstrates that it is important to develop effective educational programs suitable for each group. In particular, it seems now to be crucial to develop appropriate curricula for teaching medical and nonmedical (pharmacy, dentistry, nursing, veterinary medicine, and midwifery) undergraduate students about general medicine, microbial virulence, mechanism of antibiotic resistance, and judicious antibiotic prescribing.

Optimizing research methods used for the evaluation of antimicrobial stewardship programs

Antimicrobial stewardship programs (ASPs) are an increasingly common intervention for optimizing antimicrobial therapy in healthcare settings. These programs aim to improve patient care and limit the emergence and spread of multidrug-resistant organisms by supporting prudent antimicrobial use. However, pressure from the current reimbursement climate necessitates that ASPs operate as cost-cutting programs rather than focus on patient outcomes. This has forced the research that is evaluating ASP interventions to concentrate heavily on economic outcomes. As the science of antimicrobial stewardship advances, it is essential that well-conducted evaluations, focused on patient and microbial outcomes, serve as the evidence base that directs optimal ASP intervention design and implementation. In this review, we provide guidance and recommendations for the design of studies to evaluate the impact of ASP interventions on patient and microbial outcomes.