Antibiotic and bronchodilator prescribing for acute bronchitis in the emergency department

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.

Acute Respiratory Infection Incidence and Outpatient Antibiotic Prescription Patterns in People With or Without Human Immunodeficiency Virus Infection: A Virtual Cohort Study

Background

Inappropriate antibiotic use in acute respiratory infections (ARIs) is a major public health concern; however, data for people with human immunodeficiency virus (PWH) are limited.

Methods

The HIV Virtual Cohort Study is a retrospective cohort of adult Department of Defense beneficiaries. Male PWH cases (n = 2413) were matched 1:2 to controls without HIV (n = 4826) by age, gender, race/ethnicity, and beneficiary status. Acute respiratory infection encounters between 2016 and 2020 and corresponding antibiotic prescriptions were characterized as always, sometimes, or never appropriate based on International Classification of Diseases, Tenth Revision coding. Incidence of ARI encounters and antibiotic appropriateness were compared between PWH and controls. Subgroup analyses were assessed by CD4 count and viral load suppression on antiretroviral therapy.

Results

Mean rates of ARI encounters were similar for PWH (1066 per 1000 person-years) and controls (1010 per 1000 person-years); however, the rate was double among PWH without viral load (VL) suppression (2018 per 1000 person-years). Antibiotics were prescribed in 26% of encounters among PWH compared to 34% for controls (P ≤ .01); antibiotic use was "never" appropriate in 38% of encounters with PWH and 36% in controls. Compared to controls, PWH received more sulfonamides (5.5% vs 2.7%; P = .001), and variation existed among HIV subgroups in the prescription of sulfonamides, fluoroquinolones, and β-lactams.

Discussion

Acute respiratory infection encounters were similar for PWH and those without HIV; however, PWH with lower CD4 counts and/or nonsuppressed VL had more frequent ARI visits. Inappropriate antibiotic use for ARIs was high in both populations, and focused interventions to improve antibiotic appropriateness for prescribers caring for PWH should be pursued.

Antibiotic Prescribing for Acute Respiratory Illnesses in Persons with HIV compared to Persons without HIV

Background

Antibiotic overuse increases healthcare cost and promotes antimicrobial resistance. People with HIV (PWH) who develop acute respiratory infections (ARI) may be assumed “higher risk,” compared with non-PWH, but comparative antibiotic use evaluations have not been performed.

Methods

This observational, single-center study compared antibiotic prescribing in independent clinical encounters for PWH and non-PWH diagnosed with ARI in outpatient clinical practices using ICD 10 codes between January 1, 2014 and April 30, 2018. Fisher’s exact test compared categorical variables with antibiotic prescribing patterns.

Results

There were 209 patients in the PWH cohort vs. 398 patients in the non-PWH cohort. PWH had median CD4+ count of 610 cells/mm3 with 91% on antiretroviral therapy and 78% were virally suppressed. Thirty-seven percent of all visits resulted in an antibiotic prescription, 89% were inappropriate. Antibiotics were prescribed more frequently in non-PWH (35% PWH vs. 40% non-PWH; p 0.172) and managed according to guidelines more often in PWH (37% PWH vs. 30% non-PWH; p 0.039). Antibiotics were prescribed appropriately most frequently in PWH managed by HIV clinicians (29% PWH managed by HIV clinician vs. 12% PWH managed by non-HIV clinician vs. 8% non-PWH p 0.010). HIV clinicians prescribed antibiotics for a mean duration of 5.9 days vs. PWH managed by a non-HIV clinician for 9.1 days vs. non-PWH for 7.6 days (p <0.0001).

Conclusion

Outpatient antibiotic overuse remains prevalent among patients evaluated for ARI. We found less frequent inappropriate antibiotic use in PWH. Prescriber specialty, rather than HIV diagnosis, was related to appropriateness of antimicrobial prescribing.

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.

Assessment of quarter billion primary care prescriptions from a nationwide antimicrobial stewardship program

We described the significance of systematic monitoring nationwide antimicrobial stewardship programs (ASPs) in primary care. All the prescriptions given by family physicians were recorded in Prescription Information System established by the Turkish Medicines and Medical Devices Agency of Ministry of Health. We calculated, for each prescription, “antibiotics amount” as number of boxes times number of items per box for medicines that belong to antiinfectives for systemic use (i.e., J01 block in the Anatomical Therapeutic Chemical Classification System). We compared the antibiotics amount before (2015) and after (2016) the extensive training programs for the family physicians. We included 266,389,209 prescriptions from state-operated family healthcare units (FHUs) between January 1, 2015 and December 31, 2016. These prescriptions were given by 26,313 individual family physicians in 22,518 FHUs for 50,713,181 individual patients. At least one antimicrobial was given in 37,024,232 (28.31%) prescriptions in 2015 and 36,154,684 (26.66%) prescriptions in 2016. The most common diagnosis was “acute upper respiratory infections (AURI)” (i.e., J00-J06 block in the 10th revision of the International Statistical Classification of Diseases and Related Health Problems) with 28.05%. The average antibiotics amount over prescriptions with AURI decreased in 79 out of 81 provinces, and overall rate of decrease in average antibiotics amount was 8.33%, where 28 and 53 provinces experienced decreases (range is between 28.63% and −3.05%) above and below this value, respectively. In the most successful province, the highest decrease in average amount of “other beta-lactam antibacterials” per prescription for AURI was 49.63% in January. Computational analyses on a big data set collected from a nationwide healthcare system brought a significant contribution in improving ASPs.

Decreased Overall and Inappropriate Antibiotic Prescribing in a Veterans Affairs Hospital Emergency Department following a Peer Comparison-Based Stewardship Intervention

Antibiotic prescribing is very common in emergency departments (EDs). Optimal stewardship intervention strategies in EDs are not well defined. We conducted a prospective, observational cohort study in a Veterans Affairs ED in which clinician education and monthly e-mail-based peer comparisons were directed against all oral antibiotic prescribing for discharged patients. Oral antibiotic prescriptions were compared in baseline (June 2016 to December 2017) and intervention (January to June 2018) periods using an interrupted time series regression model. Prescribing appropriateness was compared during January to June 2017 and the intervention period. During the intervention period, antibiotic prescriptions decreased monthly by 10.4 prescriptions per 1,000 ED visits (P = 0.07 [95% confidence interval {CI}, -21.7 to 1.0]). The relative decrease in the trend of antibiotic prescriptions during the intervention period compared to baseline was 9.9 prescriptions per 1,000 ED visits per month (P = 0.07 [95% CI, -20.9 to 1.0]). The intervention was associated with a significant decrease and increase in amoxicillin-clavulanate and cephalexin prescriptions, respectively (P < 0.001, P = 0.004). Decreasing trends in ciprofloxacin prescriptions during the baseline period were maintained during the intervention. Unnecessary antibiotic prescribing (i.e., antibiotic not indicated) decreased from 55.6% to 38.7% during the intervention (30.4% decrease, P = 0.003). Optimal antibiotic prescribing (i.e., antibiotics were indicated, and a guideline-concordant agent was prescribed for guideline-concordant duration) increased by 36% (21.6% to 29.3%, P = 0.12). A peer comparison-based stewardship intervention directed at ED clinicians was associated with reductions in overall and unnecessary oral antibiotic prescribing. There is potential to further improve antibiotic use as suboptimal prescribing remained common.

Collaborative Antimicrobial Stewardship in the Emergency Department

Given the large number of patients seen in the emergency department (ED) and concerns with antibiotic overprescribing, the ED is an important setting to target for antimicrobial stewardship (AS) initiatives. The ED is positioned between ambulatory and inpatient settings, making AS collaboration with clinicians and other health care providers in the hospital, long-term care facilities, and ambulatory settings critical to success. This article details ED-focused AS strategies on empiric antimicrobial selection, prompt administration, preventing ED return and readmissions, suggested collaborations between ED AS leadership and other key partners, and potential future strategies for expansion.

Considerations for Designing EHR-Embedded Clinical Decision Support Systems for Antimicrobial Stewardship in Pediatric Emergency Departments

OBJECTIVE

This study was aimed to explore the intersection between organizational environment, workflow, and technology in pediatric emergency departments (EDs) and how these factors impact antibiotic prescribing decisions.

METHODS

Semistructured interviews with 17 providers (1 fellow and 16 attending faculty), and observations of 21 providers (1 physician assistant, 5 residents, 3 fellows, and 12 attendings) were conducted at three EDs in the United States. We analyzed interview transcripts and observation notes using thematic analysis.

RESULTS

Seven themes relating to antibiotic prescribing decisions emerged as follows: (1) professional judgement, (2) cognition as a critical individual resource, (3) decision support as a critical organizational resource, (4) patient management with imperfect information, (5) information-seeking as a primary task, (6) time management, and (7) broad process boundaries of antibiotic prescribing.

DISCUSSION

The emerging interrelated themes identified in this study can be used as a blueprint to design, implement, and evaluate clinical decision support (CDS) systems that support antibiotic prescribing in EDs. The process boundaries of antibiotic prescribing are broader than the current boundaries covered by existing CDS systems. Incongruities between process boundaries and CDS can under-support clinicians and lead to suboptimal decisions. We identified two incongruities: (1) the lack of acknowledgment that the process boundaries go beyond the physical boundaries of the ED and (2) the lack of integration of information sources (e.g., accessibility to prior cultures on an individual patient outside of the organization).

CONCLUSION

Significant opportunities exist to improve appropriateness of antibiotic prescribing by considering process boundaries in the design, implementation, and evaluation of CDS systems.

Cost Impact Model of a Novel Multi-mRNA Host Response Assay for Diagnosis and Risk Assessment of Acute Respiratory Tract Infections and Sepsis in the Emergency Department

BACKGROUND

Early identification of acute infections and sepsis remains an unmet medical need. While early detection and initiation of treatment reduces mortality, inappropriate treatment leads to adverse events and the development of antimicrobial resistance. Current diagnostic and prognostic solutions, including procalcitonin, lack required accuracy. A novel blood-based host response test, HostDx™ Sepsis by Inflammatix, Inc., assesses the likelihood of a bacterial infection, the likelihood of a viral infection, and the severity of the condition.

OBJECTIVES

We estimated the economic impact of adopting HostDx Sepsis testing among patients with suspected acute respiratory tract infection (ARTI) in the emergency department (ED).

METHODS

Our cost impact model estimated costs for adult ED patients with suspected ARTI under the standard of care versus with the adoption of HostDx Sepsis from the perspective of US payers. Included costs were those assumed to be associated with an episode of sepsis diagnosis, management, and treatment. Projected accuracies for test predictions, disease prevalence, and clinical parameters was derived from patient-level meta-analysis data of randomized trials, supplemented with published performance data for HostDx Sepsis. One-way sensitivity analysis was performed on key input parameters.

RESULTS

Compared to standard of care including procalcitonin, the superior test characteristics of HostDx Sepsis resulted in an average cost savings of approximately US$1974 per patient (-31.3%) exclusive of the cost of HostDx Sepsis. Reductions in hospital days (-0.80 days, -36.7%), antibiotic days (-1.49 days, -29.5%), and percent 30-day mortality (-1.67%, -13.64%) were driven by HostDx Sepsis providing fewer "noninformative" moderate risk predictions and more "certain" low- or high-risk predictions compared to standard of care, especially for patients who were not severely ill. These results were robust to changes in key parameters, including disease prevalence.

CONCLUSIONS

Our model shows substantial savings associated with introduction of HostDx Sepsis among patients with ARTIs in EDs. These results need confirmation in interventional trials.

Antibiotic Prescribing for Acute Respiratory Tract Infections 12 Months After Communication and CRP Training: A Randomized Trial

PURPOSE

C-reactive-protein (CRP) is useful for diagnosis of lower respiratory tract infections (RTIs). A large international trial documented that Internet-based training in CRP point-of-care testing, in enhanced communication skills, or both reduced antibiotic prescribing at 3 months, with risk ratios (RRs) of 0.68, 0.53, 0.38, respectively. We report the longer-term impact in this trial.

METHODS

A total of 246 general practices in 6 countries were cluster-randomized to usual care, Internet-based training on CRP point-of-care testing, Internet-based training on enhanced communication skills and interactive booklet, or both interventions combined. The main outcome was antibiotic prescribing for RTIs after 12 months.

RESULTS

Of 228 practices providing 3-month data, 74% provided 12-month data, with no demonstrable attrition bias. Between 3 months and 12 months, prescribing for RTIs decreased with usual care (from 58% to 51%), but increased with CRP training (from 35% to 43%) and with both interventions combined (from 32% to 45%); at 12 months, the adjusted RRs compared with usual care were 0.75 (95% CI, 0.51-1.00) and 0.70 (95% CI, 0.49-0.93), respectively. Between 3 months and 12 months, the reduction in prescribing with communication training was maintained (41% and 40%, with an RR at 12 months of 0.70 [95% CI, 0.49-0.94]). Although materials were provided for free, clinicians seldom used booklets and rarely used CRP point-of-care testing. Communication training, but not CRP training, remained efficacious for reducing prescribing for lower RTIs (RR = 0.7195% CI, 0.45-0.99, and RR = 0.76; 95% CI, 0.47-1.06, respectively), whereas both remained efficacious for reducing prescribing for upper RTIs (RR = 0.60; 95% CI, 0.37-0.94, and RR = 0.58; 95% CI, 0.36-0.92, respectively).

CONCLUSIONS

Internet-based training in enhanced communication skills remains effective in the longer term for reducing antibiotic prescribing. The early improvement seen with CRP training wanes, and this training becomes ineffective for lower RTIs, the only current indication for using CRP testing.

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.

Efficacy and safety of HL301 in the treatment of acute bronchitis and acute exacerbation of chronic bronchitis: a phase 2, randomized, double-blind, placebo-controlled, multicenter study

PURPOSE

The efficacy and safety of Chinese herbs for symptomatic treatment of bronchitis is not well established. We evaluated the efficacy and safety of a combination product of seven herbs (HL301) for the treatment of acute bronchitis (AB) and acute exacerbation of chronic bronchitis (AECB) using a randomized, double-blind, placebo-controlled, multicenter trial design.

METHODS

A total of 160 patients with AB or with AECB were randomized to receive placebo or one of three doses of HL301 (0.6 g/day, 1.2 g/day, or 1.8 g/day) for a total of 7 days. The primary study endpoint was the change in bronchitis severity score (BSS) from the baseline visit (visit 2) to the end of treatment visit (visit 3). Other efficacy variables were percentage BSS systemic sign efficacy after treatment and change in individual BSS parameters after treatment.

FINDINGS

Changes in BSS from visit 2 to visit 3 in the three treatment groups (4.63 ± 2.24, 4.08 ± 1.63, and 4.15 ± 1.74 in the HL301 0.6 g/day, 1.2 g/day, and 1.8 g/day groups, respectively) were higher than that of the placebo group (2.88 ± 2.57) in the per protocol set (PPS) (P < .05), and it was also valid in the full analysis set (FAS). The number of participants whose symptoms (measured by BSS) improved at least 30% after treatment was higher in all three treatment groups compared to the placebo group in both the FAS and the PPS (P < .05, for all).

IMPLICATIONS

Three different doses of HL301 (0.6 g/day, 1.2 g/day, and 1.8 g/day) were effective in decreasing the BSS index compared to placebo. HL301 may be effective for symptomatic treatment of both AB and AECB.

LIMITATIONS

Essential components of HL301 have not been delineated in the study and patients with AB and AECB were indiscriminately enrolled in the present study. Respective evaluation of the efficacy of HL301 for AB and AECB will be necessary in the future.

Reducing Inappropriate Antibiotic Prescribing for Adults With Acute Bronchitis in an Urgent Care Setting: A Quality Improvement Initiative

Acute bronchitis is a predominantly viral illness and, according to clinical practice guidelines, should not be treated with antibiotics. Despite clear guidelines, acute bronchitis continues to be the most common acute respiratory illness for which antibiotics are incorrectly prescribed. Although the national benchmark for antibiotic prescribing for adults with acute bronchitis is 0%, a preliminary record review before implementing the intervention at the project setting showed that 96% (N = 30) of adults with acute bronchitis in this setting were prescribed an antibiotic. This quality improvement project utilized a single-group, pre-post design. The setting for this project was a large urgent care network with numerous locations in central North Carolina. The purpose was to determine whether nurse practitioners and physician assistants, after participating in a multifaceted provider education session, would reduce inappropriate antibiotic prescribing for healthy adults with acute uncomplicated bronchitis. Twenty providers attended 1 of 4 training sessions offered in October and November 2015. The face-to-face interactive training sessions focused on factors associated with inappropriate antibiotic prescribing, current clinical practice guidelines, and patient communication skills. Retrospective medical record review of 217 pretraining and 335 posttraining encounters for acute bronchitis by 19 eligible participating providers demonstrated a 61.9% reduction in immediate antibiotic prescribing from 91.7% to 29.8%. Delayed prescribing, which accounted for a small percentage of the total prescriptions given, had a small but significant increase of 9.3% after training. Overall, this multifaceted, interactive provider training resulted in significant reductions in inappropriate prescriptions.

Antibiotic prescriptions for suspected respiratory tract infection in primary care in South America

OBJECTIVES

To describe and compare antibiotic prescribing patterns for primary care patients with respiratory tract infections (RTIs) in four South American countries.

METHODS

This was a prospective observational study. General practitioners (GPs) from Argentina, Bolivia, Paraguay and Uruguay registered data about all consultations of patients with suspected RTIs in the winter of 2014 (June-August). Variation in antibiotic prescriptions was assessed using a two-level hierarchical logistic model.

RESULTS

Participating GPs (n = 171) registered 11 446 patients with suspected RTI; 3701 (33%) of these received an antibiotic prescription. There was a wide variation across countries in the use and selection of antibiotics. For example, 94% of patients with acute bronchitis were prescribed antibiotics in Bolivia, while in Uruguay only 21% received antibiotics. Amoxicillin was the most commonly prescribed antibiotic across countries, but prescription rates varied between 45% in Bolivia and 69% in Uruguay. Compared with the overall mean prescribing rate, and after adjusting for clinical presentation and demographics, prescribing of antibiotics varied by a factor of 6, the OR ranging from 0.37 (95% CI = 0.21-0.65) in Uruguay to 2.58 (95% CI = 1.66-4) in Bolivia.

CONCLUSIONS

The large variation in use and selection of antibiotics across countries is not explained by different patient populations. It could be explained by diagnostic uncertainty and contextual characteristics beyond clinical practice. Reducing uncertainty and country variation requires greater support from the healthcare systems by providing GPs with evidence-based guidelines and tools to apply them.

Antibiotics for respiratory tract infections: a comparison of prescribing in an outpatient setting

OBJECTIVE

To examine inappropriate antibiotic prescribing for acute respiratory tract infections (RTIs) in ambulatory care to help target antimicrobial stewardship interventions. Design and Setting Retrospective analysis of RTI visits within general internal medicine (GIM) and family medicine (FM) ambulatory practices at an inner-city academic medical center from 2008 to 2010.

METHODS

Patient, physician, and practice characteristics were analyzed using multivariable logistic regression to determine factors predictive of inappropriate prescribing; physicians in the highest and lowest antibiotic-prescribing quartiles were compared using χ2 analysis.

RESULTS

Visits with FM providers, female gender, and self-reported race/ethnicity as white or Hispanic were significantly associated with inappropriate antibiotic prescribing. Physicians in the lowest quartile prescribed antibiotics for 5%-28% (mean, 21%) of RTI visits; physicians in the highest quartile prescribed antibiotics for 54%-85% (mean, 65%) of RTI visits. High prescribers had fewer African-American patients and more patients who were younger and privately insured. High prescribers had more patients with chronic lung disease. A GIM practice pod with a low prescriber was 3.0 times more likely to have a second low prescriber than other practice pods, whereas pods with a high prescriber were 1.3 times more likely to have a second high prescriber.

CONCLUSIONS

Medical specialty was the only physician factor predictive of inappropriate prescribing when patient gender, race, and comorbidities were taken into account. Possible disparities in care need further study. Stewardship education in medical school, enlisting low prescribers as physician leaders, and targeting interventions to the highest prescribers might be more effective approaches to antimicrobial stewardship.

Antimicrobial Stewardship in the Emergency Department: Challenges, Opportunities, and a Call to Action for Pharmacists

Antimicrobial resistance is a national public health concern. Misuse of antimicrobials for conditions such as upper respiratory infection, urinary tract infections, and cellulitis has led to increased resistance to antimicrobials commonly utilized to treat those infections, such as sulfamethoxazole/trimethoprim and flouroquinolones. The emergency department (ED) is a site where these infections are commonly encountered both in ambulatory patients and in patients requiring admission to a hospital. The ED is uniquely positioned to affect the antimicrobial use and resistance patterns in both ambulatory settings and inpatient settings. However, implementing antimicrobial stewardship programs in the ED is fraught with challenges including diagnostic uncertainty, distractions secondary to patient or clinician turnover, and concerns with patient satisfaction to name just a few. However, this review article highlights successful interventions that have stemmed inappropriate antimicrobial use in the ED setting and warrant further study. This article also proposes other, yet to be validated proposals. Finally, this article serves as a call to action for pharmacists working in antimicrobial stewardship programs and in emergency medicine settings. There needs to be further research on the implementation of these and other interventions to reduce inappropriate antimicrobial use to prevent patient harm and curb the development of antimicrobial resistance.

Clinical and haematological predictors of antibiotic prescribing for acute cough in adults in Swiss practices--an observational study

Background

Acute cough is a common problem in general practice and is often caused by a self-limiting, viral infection. Nonetheless, antibiotics are often prescribed in this situation, which may lead to unnecessary side effects and, even worse, the development of antibiotic resistant microorganisms worldwide. This study assessed the role of point-of-care C-reactive protein (CRP) testing and other predictors of antibiotic prescription in patients who present with acute cough in general practice.

Methods

Patient characteristics, symptoms, signs, and laboratory and X-ray findings from 348 patients presenting to 39 general practitioners with acute cough, as well as the GPs themselves, were recorded by fourth-year medical students during their three-week clerkships in general practice. Patient and clinician characteristics of those prescribed and not-prescribed antibiotics were compared using a mixed-effects model.

Results

Of 315 patients included in the study, 22% were prescribed antibiotics. The two groups of patients, those prescribed antibiotics and those treated symptomatically, differed significantly in age, demand for antibiotics, days of cough, rhinitis, lung auscultation, haemoglobin level, white blood cell count, CRP level and the GP’s license to self-dispense antibiotics. After regression analysis, only the CRP level, the white blood cell count and the duration of the symptoms were statistically significant predictors of antibiotic prescription.

Conclusions

The antibiotic prescription rate of 22% in adult patients with acute cough in the Swiss primary care setting is low compared to other countries. GPs appear to use point-of-care CRP testing in addition to the duration of clinical symptoms to help them decide whether or not to prescribe antibiotics.

Antibiotic Prescriptions for Upper Respiratory Infection in the Emergency Department: A Population-Based Study

Study Objective. Antibiotics prescriptions for upper respiratory infections (URI) are not uncommon, but the benefits for these groups had seldom been evaluated. We aimed to utilize a sampled National Health Insurance (NHI) claims data containing one million beneficiaries to explore if the use of antibiotics could reduce the possibility of unscheduled returns. Methods. We identified patients presented to ambulatory clinics with the discharged diagnoses of URI. The prescriptions of antibiotics were identified. We further matched each patient in the antibiotic group to the patient in the control group by selected covariates using a standard propensity score greedy-matching algorithm. The risks of unscheduled revisits were compared between the two groups. Results. A total of 6915140 visits were identified between 2005 and 2010. The proportions of antibiotics prescriptions are similar among these years, ranging from 9.99% to 13.38 %. In the propensity score assignment, 9190 patients (4595 in each group) were further selected. The odds ratio of unscheduled revisits among antibiotics group and control group was 0.92 (95% CI, 0.70–1.22) with P value equal to 0.569. Conclusions. Overall, antibiotics prescriptions did not seem to decrease the unscheduled revisits in patients presented to the ED with URI. Emergency physicians should reduce the unnecessary prescriptions and save antibiotics to patients with real benefits.

Effects of internet-based training on antibiotic prescribing rates for acute respiratory-tract infections: a multinational, cluster, randomised, factorial, controlled trial

BACKGROUND

High-volume prescribing of antibiotics in primary care is a major driver of antibiotic resistance. Education of physicians and patients can lower prescribing levels, but it frequently relies on highly trained staff. We assessed whether internet-based training methods could alter prescribing practices in multiple health-care systems.

METHODS

After a baseline audit in October to December, 2010, primary-care practices in six European countries were cluster randomised to usual care, training in the use of a C-reactive protein (CRP) test at point of care, in enhanced communication skills, or in both CRP and enhanced communication. Patients were recruited from February to May, 2011. This trial is registered, number ISRCTN99871214.

RESULTS

The baseline audit, done in 259 practices, provided data for 6771 patients with lower-respiratory-tract infections (3742 [55·3%]) and upper-respiratory-tract infections (1416 [20·9%]), of whom 5355 (79·1%) were prescribed antibiotics. After randomisation, 246 practices were included and 4264 patients were recruited. The antibiotic prescribing rate was lower with CRP training than without (33% vs 48%, adjusted risk ratio 0·54, 95% CI 0·42-0·69) and with enhanced-communication training than without (36% vs 45%, 0·69, 0·54-0·87). The combined intervention was associated with the greatest reduction in prescribing rate (CRP risk ratio 0·53, 95% CI 0·36-0·74, p<0·0001; enhanced communication 0·68, 0·50-0·89, p=0·003; combined 0·38, 0·25-0·55, p<0·0001).

INTERPRETATION

Internet training achieved important reductions in antibiotic prescribing for respiratory-tract infections across language and cultural boundaries.

FUNDING

European Commission Framework Programme 6, National Institute for Health Research, Research Foundation Flanders.