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Ramanathan S, Yan C, Suda KJ, Evans CT, Khouja T, Hershow RC, Rowan SA, Gross AE, Sharp LK. Barriers and facilitators to guideline concordant dental antibiotic prescribing in the United States: A qualitative study of the National Dental PBRN. J Public Health Dent 2024; 84:163-174. [PMID: 38558016 DOI: 10.1111/jphd.12611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 01/22/2024] [Accepted: 02/09/2024] [Indexed: 04/04/2024]
Abstract
OBJECTIVES While factors contributing to dental antibiotic overprescribing have previously been described, previous work has lacked any theoretical behavior change framework that could guide future intervention development. The purpose of this study was to use an evidence-based conceptual model to identify barriers and facilitators of appropriate antibiotic prescribing by dentists as a guide for future interventions aimed at modifying antibiotic prescribing. METHODS Semi-structured interviews were conducted with dentists from the National Dental Practice Based Research Network (PBRN) exploring patient and practice factors perceived to impact antibiotic prescribing. Audio-recorded telephone interviews were transcribed and independently coded by three researchers. Themes were organized around the COM-B model to inform prospective interventions. RESULTS 73 of 104 dentists (70.1%) were interviewed. Most were general dentists (86.3%), male (65.7%), and white (69.9%). Coding identified three broad targets to support appropriate dental antibiotic prescribing among dentists: (1) increasing visibility and accessibility of guidelines, (2) providing additional guidance on antibiotic prescribing in dental scenarios without clear guidelines, and (3) education and communication skills-building focused on discussing appropriate antibiotic use with patients and physicians. CONCLUSIONS The findings from our study are consistent with other studies focusing on antibiotic prescribing behavior in dentists. Understanding facilitators and barriers to dental antibiotic prescribing is necessary to inform targeted interventions to improve appropriate antibiotic prescribing. Future interventions should focus on implementing multimodal strategies to provide the necessary support for dentists to judiciously prescribe antibiotics.
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Affiliation(s)
- Swetha Ramanathan
- School of Public Health, University of Illinois at Chicago, Chicago, Illinois, USA
- Center of Innovation for Complex Chronic Healthcare, Hines VA Hospital, Hines, Illinois, USA
| | - Connie Yan
- College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Katie J Suda
- Center for Health Equity Research and Promotion, VA Pittsburgh Health System, Pittsburgh, Pennsylvania, USA
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Charlesnika T Evans
- Center of Innovation for Complex Chronic Healthcare, Hines VA Hospital, Hines, Illinois, USA
- Department of Preventive Medicine and Center for Health Services and Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Tumader Khouja
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ronald C Hershow
- School of Public Health, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Susan A Rowan
- College of Dentistry, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Alan E Gross
- College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Lisa K Sharp
- College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois, USA
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Festok RA, Ahuja AS, Chen JY, Chu L, Barron J, Case K, Thompson E, Chen SC, Weiss J, Swerlick RA, Escoffery C, Yeung H. Barriers and Facilitators Affecting Long-Term Antibiotic Prescriptions for Acne Treatment. JAMA Dermatol 2024; 160:535-543. [PMID: 38568616 PMCID: PMC10993164 DOI: 10.1001/jamadermatol.2024.0203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 01/27/2024] [Indexed: 04/06/2024]
Abstract
Importance Dermatologists prescribe more oral antibiotics per clinician than clinicians in any other specialty. Despite clinical guidelines that recommend limitation of long-term oral antibiotic treatments for acne to less than 3 months, there is little evidence to guide the design and implementation of an antibiotic stewardship program in clinical practice. Objective To identify salient barriers and facilitators to long-term antibiotic prescriptions for acne treatment. Design, Setting, and Participants This qualitative study assessed data collected from stakeholders (including dermatologists, infectious disease physicians, dermatology resident physicians, and nonphysician clinicians) via an online survey and semistructured video interviews between March and August 2021. Data analyses were performed from August 12, 2021, to January 20, 2024. Main Outcomes and Measures Online survey and qualitative video interviews developed with the Theoretical Domains Framework. Thematic analyses were used to identify salient themes on barriers and facilitators to long-term antibiotic prescriptions for acne treatment. Results Among 30 participants (14 [47%] males and 16 [53%] females) who completed the study requirements and were included in the analysis, knowledge of antibiotic guideline recommendations was high and antibiotic stewardship was believed to be a professional responsibility. Five salient themes were to be affecting long-term antibiotic prescriptions: perceived lack of evidence to justify change in dermatologic practice, difficulty navigating patient demands and satisfaction, discomfort with discussing contraception, iPLEDGE-related barriers, and the absence of an effective system to measure progress on antibiotic stewardship. Conclusions and Relevance The findings of this qualitative study indicate that multiple salient factors affect long-term antibiotic prescribing practices for acne treatment. These factors should be considered in the design and implementation of any future outpatient antibiotic stewardship program for clinical dermatology.
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Affiliation(s)
- Ronnie A. Festok
- Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia
| | - Avni S. Ahuja
- Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia
| | - Jared Y. Chen
- Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia
| | - Lena Chu
- Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia
| | - Jason Barron
- Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia
| | - Katherine Case
- Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia
| | - Elaine Thompson
- Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia
| | - Suephy C. Chen
- Department of Dermatology, Duke University School of Medicine, Durham, North Carolina
- Division of Dermatology, Durham VA Medical Center, Durham, North Carolina
| | - Jonathan Weiss
- Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia
| | - Robert A. Swerlick
- Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia
| | - Cam Escoffery
- Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia
| | - Howa Yeung
- Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia
- Associate Editor, JAMA Dermatology
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Toghroli R, Hassani L, Aghamolaei T, Sharma M, Sharifi H, Jajarmi M. Explaining the barriers faced by veterinarians against preventing antimicrobial resistance: an innovative interdisciplinary qualitative study. BMC Infect Dis 2024; 24:455. [PMID: 38689250 PMCID: PMC11059684 DOI: 10.1186/s12879-024-09352-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 04/25/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND Considering the significance of increased antimicrobial resistance (AMR) and its adverse effects on individual and social health and the important and effective role that veterinarians play in controlling this growing issue worldwide, it is essential to have effective preventive control programs. To this aim, the first step is to identify the factors behind the prevalence of AMR in Iran and the barriers veterinarians face to controlling this problem. Thus, the present study was conducted to explain the barriers veterinarians faced in the prevention of AMR from an Iranian veterinarian's perspective. METHODS The present research was done in three cities in Iran in 2021. The data were collected through in-depth interviews with 18 veterinarians selected through purposive and snowball sampling and analyzed using conventional qualitative content analysis. RESULTS The data analysis results were classified into 4 main categories and 44 subcategories. The former included: educational factors, administrative/legal factors, client-related factors, and veterinarian-related factors. CONCLUSIONS The increased AMR can be approached from multiple aspects. Considering the different factors that affect the increased AMR, it is necessary to consider them all through effective planning and policy-making at multi-level and multidisciplinary dimensions. There is special attention needed to scientific and practical interventions at the individual, interpersonal, social, and even political levels. At the same time, measures should be taken to rehabilitate and maintain the health of society to strengthen supervision and attract the full participation of interested organizations.
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Affiliation(s)
- Razie Toghroli
- Social Determinants in Health Promotion Research Center, Hormozgan Health Institute, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
| | - Laleh Hassani
- Social Determinants in Health Promotion Research Center, Hormozgan Health Institute, Hormozgan University of Medical Sciences, Bandar Abbas, Iran.
| | - Teamur Aghamolaei
- Social Determinants in Health Promotion Research Center, Hormozgan Health Institute, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
| | - Manoj Sharma
- Department of Social and Behavioral Health, School of Public Health, University of Nevada, Las Vegas (UNLV), Las Vegas, NV, 89119, USA
| | - Hamid Sharifi
- HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
- Institute for Global Health Sciences, University of California, San Francisco, CA, USA
| | - Maziar Jajarmi
- Department of Pathobiology, Faculty of Veterinary Medicine, Shahid Bahonar University of Kerman, Kerman, Iran
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Guisado-Gil AB, Mejías-Trueba M, Peñalva G, Aguilar-Guisado M, Molina J, Gimeno A, Álvarez-Marín R, Praena J, Bueno C, Lepe JA, Gil-Navarro MV, Cisneros JM. Antimicrobial Stewardship in the Emergency Department Observation Unit: Definition of a New Indicator and Evaluation of Antimicrobial Use and Clinical Outcomes. Antibiotics (Basel) 2024; 13:356. [PMID: 38667032 PMCID: PMC11047618 DOI: 10.3390/antibiotics13040356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 03/27/2024] [Accepted: 04/10/2024] [Indexed: 04/29/2024] Open
Abstract
We aimed to define a novel indicator for monitoring antimicrobial use specifically in the Emergency Department Observation Unit (EDOU) and to assess the long-term impact of an institutional education-based antimicrobial stewardship program (ASP) on the antimicrobial prescribing pattern and clinical outcomes in this setting. A quasi-experimental interrupted time-series study was performed from 2011 to 2022. An educational ASP was implemented at the EDOU in 2015. To estimate changes in antimicrobial use, we designed an indicator adjusted for patients at risk of antimicrobial prescribing: defined daily doses (DDDs) per 100 patients transferred from the Emergency Department to the Observation Unit (TOs) per quarter. The number of bloodstream infections (BSIs) and the crude all-cause 14-day mortality were assessed as clinical outcomes. Antimicrobial use showed a sustained reduction with a trend change of -1.17 DDD per 100 TO and a relative effect of -45.6% (CI95% -64.5 to -26.7), particularly relevant for meropenem and piperacillin-tazobactam, with relative effects of -80.4% (-115.0 to -45.7) and -67.9% (-93.9 to -41.9), respectively. The incidence density of all BSIs increased significantly during the ASP period, with a relative effect of 123.2% (41.3 to 284.7). The mortality rate remained low and stable throughout the study period, with an absolute effect of -0.7% (-16.0 to 14.7). The regular monitoring of antimicrobial use in the EDOU by using this new quantitative indicator was useful to demonstrate that an institutional education-based ASP successfully achieved a long-term reduction in overall antimicrobial use, with a low and steady BSI mortality rate.
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Affiliation(s)
- Ana Belén Guisado-Gil
- Department of Infectious Diseases, Microbiology and Parasitology, Virgen del Rocío University Hospital, 41013 Seville, Spain; (A.B.G.-G.)
- Department of Pharmacy, Virgen del Rocío University Hospital, 41013 Seville, Spain
- Institute of Biomedicine of Seville, Virgen del Rocío University Hospital/CSIC/University of Seville, 41013 Seville, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), 28029 Madrid, Spain
| | - Marta Mejías-Trueba
- Department of Infectious Diseases, Microbiology and Parasitology, Virgen del Rocío University Hospital, 41013 Seville, Spain; (A.B.G.-G.)
- Department of Pharmacy, Virgen del Rocío University Hospital, 41013 Seville, Spain
- Institute of Biomedicine of Seville, Virgen del Rocío University Hospital/CSIC/University of Seville, 41013 Seville, Spain
| | - Germán Peñalva
- Department of Infectious Diseases, Microbiology and Parasitology, Virgen del Rocío University Hospital, 41013 Seville, Spain; (A.B.G.-G.)
- Institute of Biomedicine of Seville, Virgen del Rocío University Hospital/CSIC/University of Seville, 41013 Seville, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), 28029 Madrid, Spain
| | - Manuela Aguilar-Guisado
- Department of Infectious Diseases, Microbiology and Parasitology, Virgen del Rocío University Hospital, 41013 Seville, Spain; (A.B.G.-G.)
- Institute of Biomedicine of Seville, Virgen del Rocío University Hospital/CSIC/University of Seville, 41013 Seville, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), 28029 Madrid, Spain
| | - Jose Molina
- Department of Infectious Diseases, Microbiology and Parasitology, Virgen del Rocío University Hospital, 41013 Seville, Spain; (A.B.G.-G.)
- Institute of Biomedicine of Seville, Virgen del Rocío University Hospital/CSIC/University of Seville, 41013 Seville, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), 28029 Madrid, Spain
| | - Adelina Gimeno
- Department of Infectious Diseases, Microbiology and Parasitology, Virgen del Rocío University Hospital, 41013 Seville, Spain; (A.B.G.-G.)
- Institute of Biomedicine of Seville, Virgen del Rocío University Hospital/CSIC/University of Seville, 41013 Seville, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), 28029 Madrid, Spain
| | - Rocío Álvarez-Marín
- Department of Infectious Diseases, Microbiology and Parasitology, Virgen del Rocío University Hospital, 41013 Seville, Spain; (A.B.G.-G.)
- Institute of Biomedicine of Seville, Virgen del Rocío University Hospital/CSIC/University of Seville, 41013 Seville, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), 28029 Madrid, Spain
| | - Julia Praena
- Department of Infectious Diseases, Microbiology and Parasitology, Virgen del Rocío University Hospital, 41013 Seville, Spain; (A.B.G.-G.)
- Institute of Biomedicine of Seville, Virgen del Rocío University Hospital/CSIC/University of Seville, 41013 Seville, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), 28029 Madrid, Spain
| | - Claudio Bueno
- Emergency Department, Virgen del Rocío University Hospital, 41013 Seville, Spain
| | - José Antonio Lepe
- Department of Infectious Diseases, Microbiology and Parasitology, Virgen del Rocío University Hospital, 41013 Seville, Spain; (A.B.G.-G.)
- Institute of Biomedicine of Seville, Virgen del Rocío University Hospital/CSIC/University of Seville, 41013 Seville, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), 28029 Madrid, Spain
| | - María Victoria Gil-Navarro
- Department of Pharmacy, Virgen del Rocío University Hospital, 41013 Seville, Spain
- Institute of Biomedicine of Seville, Virgen del Rocío University Hospital/CSIC/University of Seville, 41013 Seville, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), 28029 Madrid, Spain
| | - José Miguel Cisneros
- Department of Infectious Diseases, Microbiology and Parasitology, Virgen del Rocío University Hospital, 41013 Seville, Spain; (A.B.G.-G.)
- Institute of Biomedicine of Seville, Virgen del Rocío University Hospital/CSIC/University of Seville, 41013 Seville, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), 28029 Madrid, Spain
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5
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Alkadhimi A, Dawood OT, Khan AH. The role of community pharmacists and their perception towards antimicrobial stewardship in Baghdad, Iraq. HEALTH CARE SCIENCE 2024; 3:114-123. [PMID: 38939617 PMCID: PMC11080847 DOI: 10.1002/hcs2.92] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 02/23/2024] [Accepted: 03/07/2024] [Indexed: 06/29/2024]
Abstract
Background This study aimed to assess the role of community pharmacists and their perception toward antimicrobial stewardship, in addition to identifying factors influencing their perception and practices in community pharmacy. Methods A cross-sectional study was carried out among community pharmacists regarding antimicrobial stewardship. Convenience sampling was used to obtain the required sample from a community pharmacy in Baghdad. In total, 381 participants have completed the survey. Results The majority of the participants (85.6%) strongly agreed/agreed that "antimicrobial stewardship programs reduce the problems of antibiotic resistance"; and 85.5% of them strongly agreed/agreed that community pharmacists required adequate training on antibiotics use. In addition, high percent of community pharmacists (88.4%) strongly agreed/agreed that pharmacists have a responsibility to take a prominent role in antimicrobial stewardship programs and infection-control programs in the health system. The total score of perception was significantly influenced by older age groups, postgraduate degrees, and experience of 6-10 years (p < 0.001). This study also showed that 65.4% of pharmacists always/often advise patients to continue the full course of antimicrobials, and 64.9% of them reported always/often considering clinical and safety parameters before dispensing antibiotics. The role of pharmacists was significantly influenced by the younger age group, females, higher degree in pharmacy, experience of 3-5 years, and medical complex pharmacy (p < 0.001). Conclusion Community pharmacists have a good perception toward antimicrobial stewardship programs, but their role is still limited. More efforts are needed to design better strategies for antimicrobial stewardship in community pharmacy.
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Affiliation(s)
- Akram Alkadhimi
- Discipline of Clinical Pharmacy, School of Pharmaceutical SciencesUniversiti Sains MalaysiaPenangMalaysia
| | | | - Amer H. Khan
- Discipline of Clinical Pharmacy, School of Pharmaceutical SciencesUniversiti Sains MalaysiaPenangMalaysia
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Ruiz Ramos J, Santolaya Perrín MR, González Del Castillo J, Candel FJ, Quirós AM, López-Contreras González J, Jiménez AJ, Suárez-Lledó Grande A. Design of a panel of indicators for antibiotic stewardship programs in the Emergency Department. FARMACIA HOSPITALARIA 2024; 48:57-63. [PMID: 37481455 DOI: 10.1016/j.farma.2023.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 06/21/2023] [Accepted: 06/22/2023] [Indexed: 07/24/2023] Open
Abstract
OBJECTIVE To develop a panel of indicators to monitor antimicrobial stewardship programs activity in the emergency department. METHODS A multidisciplinary group consisting of experts in the management of infection in emergency departments and the implementation of antimicrobial stewardship programs (ASP) evaluated a proposal of indicators using a modified Delphi methodology. In the first round, each expert classified the relevance of each proposed indicators in two dimensions (healthcare impact and ease of implementation) and two attributes (prioritization level and frequency). The second round was conducted based on the modified questionnaire according to the suggestions raised and new indicators suggested. Experts modified the prioritization order and rated the new indicators in the same manner as in the first round. RESULTS 61 potential indicators divided into four groups were proposed: consumption indicators, microbiological indicators, process indicators, and outcome indicators. After analyzing the scores and comments from the first round, 31 indicators were classified as high priority, 25 as intermediate priority, and 5 as low priority. Moreover, 18 new indicators were generated. Following the second round, all 61 initially proposed indicators were retained, and 18 new indicators were incorporated: 11 classified as high priority, 3 as intermediate priority, and 4 as low priority. CONCLUSIONS The experts agreed on a panel of ASP indicators adapted to the emergency services prioritized by level of relevance. This is as a helpful tool for the development of these programs and will contribute to monitoring the appropriateness of the use of antimicrobials in these units.
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Affiliation(s)
- Jesús Ruiz Ramos
- Servicio de Farmacia, Hospital Santa Creu y San Pau, Barcelona, España.
| | | | | | - Francisco Javier Candel
- Unidad de Enfermedades Infecciosas, Hospital Clínico Universitario San Carlos, Madrid, España
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7
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Ruiz-Ramos J, Santolaya-Perrín MR, González-Del-Castillo J, Candel FJ, Martín-Quirós A, López-Contreras-González J, Julián-Jiménez A, Suárez-Lledó-Grande A. [Translated article] Design of a panel of indicators for antibiotic stewardship programs in the Emergency Department. FARMACIA HOSPITALARIA 2024; 48:T57-T63. [PMID: 38148256 DOI: 10.1016/j.farma.2023.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 06/21/2023] [Accepted: 06/22/2023] [Indexed: 12/28/2023] Open
Abstract
OBJECTIVE To develop a panel of indicators to monitor antimicrobial stewardship programs activity in the emergency department. METHODS A multidisciplinary group consisting of experts in the management of infection in emergency departments and the implementation of antimicrobial stewardship programs (ASP) evaluated a proposal of indicators using a modified Delphi methodology. In the first round, each expert classified the relevance of each proposed indicators in two dimensions (healthcare impact and ease of implementation) and two attributes (prioritisation level and frequency). The second round was conducted based on the modified questionnaire according to the suggestions raised and new indicators suggested. Experts modified the prioritisation order and rated the new indicators in the same manner as in the first round. RESULTS 61 potential indicators divided into four groups were proposed: consumption indicators, microbiological indicators, process indicators, and outcome indicators. After analysing the scores and comments from the first round, 31 indicators were classified as high priority, 25 as intermediate priority, and 5 as low priority. Moreover, 18 new indicators were generated. Following the second round, all 61 initially proposed indicators were retained, and 18 new indicators were incorporated: 11 classified as high priority, 3 as intermediate priority, and 4 as low priority. CONCLUSIONS The experts agreed on a panel of ASP Indicators adapted to the emergency services prioritised by level of relevance. This is as a helpful tool for the development of these programs and will contribute to monitoring the appropriateness of the use of antimicrobials in these units.
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Affiliation(s)
- Jesús Ruiz-Ramos
- Servicio de Farmacia, Hospital Santa Creu y San Pau, Catalonia, Spain.
| | | | | | - Francisco Javier Candel
- Infectious diseases-Clinical Microbiology, Hospital Clínico Universitario San Carlos, Madrid, Spain
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Acharya KR, Cohen A, Brankston G, Soucy JPR, Hulth A, Löfmark S, Brownstein JS, Davidovich N, Ellen ME, Fisman DN, Moran-Gilad J, Steinman A, MacFadden DR, Greer AL. An Evaluation of the Impact of an OPEN Stewardship Generated Feedback Intervention on Antibiotic Prescribing among Primary Care Veterinarians in Canada and Israel. Animals (Basel) 2024; 14:626. [PMID: 38396594 PMCID: PMC10885889 DOI: 10.3390/ani14040626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 02/06/2024] [Accepted: 02/09/2024] [Indexed: 02/25/2024] Open
Abstract
An interrupted time-series study design was implemented to evaluate the impact of antibiotic stewardship interventions on antibiotic prescribing among veterinarians. A total of 41 veterinarians were enrolled in Canada and Israel and their prescribing data between 2019 and 2021 were obtained. As an intervention, veterinarians periodically received three feedback reports comprising feedback on the participants' antibiotic prescribing and prescribing guidelines. A change in the level and trend of antibiotic prescribing after the administration of the intervention was compared using a multi-level generalized linear mixed-effect negative-binomial model. After the receipt of the first (incidence rate ratios [IRR] = 0.88; 95% confidence interval (CI): 0.79, 0.98), and second (IRR = 0.85; 95% CI: 0.75, 0.97) feedback reports, there was a reduced prescribing rate of total antibiotic when other parameters were held constant. This decline was more pronounced among Israeli veterinarians compared to Canadian veterinarians. When other parameters were held constant, the prescribing of critical antibiotics by Canadian veterinarians decreased by a factor of 0.39 compared to that of Israeli veterinarians. Evidently, antibiotic stewardship interventions can improve antibiotic prescribing in a veterinary setting. The strategy to sustain the effect of feedback reports and the determinants of differences between the two cohorts should be further explored.
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Affiliation(s)
- Kamal R. Acharya
- Department of Population Medicine, University of Guelph, Guelph, ON N1G 2W1, Canada;
| | - Adar Cohen
- Koret School of Veterinary Medicine, The Robert H. Smith Faculty of Agriculture, Food and Environment, The Hebrew University of Jerusalem, Rehovot 7610001, Israel; (A.C.); (A.S.)
| | - Gabrielle Brankston
- Department of Population Medicine, University of Guelph, Guelph, ON N1G 2W1, Canada;
| | - Jean-Paul R. Soucy
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, ON M5T 3M7, Canada; (J.-P.R.S.); (D.N.F.)
| | - Anette Hulth
- Public Health Agency of Sweden, 171 82 Stockholm, Sweden; (A.H.); (S.L.)
| | - Sonja Löfmark
- Public Health Agency of Sweden, 171 82 Stockholm, Sweden; (A.H.); (S.L.)
| | - John S. Brownstein
- Computational Epidemiology Lab, Boston Children’s Hospital, Boston, MA 02115, USA;
- Harvard Medical School, Harvard University, Boston, MA 02115, USA
| | - Nadav Davidovich
- School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva 84105, Israel; (N.D.); (J.M.-G.)
| | - Moriah E. Ellen
- Department of Health Policy and Management, Guilford Glazer Faculty of Business and Management, Ben-Gurion University of the Negev, Beer Sheva 84105, Israel
- Department of Health Policy and Management, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva 84105, Israel
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON M5T 3M6, Canada
| | - David N. Fisman
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, ON M5T 3M7, Canada; (J.-P.R.S.); (D.N.F.)
| | - Jacob Moran-Gilad
- School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva 84105, Israel; (N.D.); (J.M.-G.)
| | - Amir Steinman
- Koret School of Veterinary Medicine, The Robert H. Smith Faculty of Agriculture, Food and Environment, The Hebrew University of Jerusalem, Rehovot 7610001, Israel; (A.C.); (A.S.)
| | | | - Amy L. Greer
- Department of Population Medicine, University of Guelph, Guelph, ON N1G 2W1, Canada;
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9
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Livorsi DJ, Branch-Elliman W, Drekonja D, Echevarria KL, Fitzpatrick MA, Goetz MB, Graber CJ, Jones MM, Kelly AA, Madaras-Kelly K, Morgan DJ, Stevens VW, Suda K, Trautner BW, Ward MJ, Jump RLP. Research agenda for antibiotic stewardship within the Veterans' Health Administration, 2024-2028. Infect Control Hosp Epidemiol 2024:1-7. [PMID: 38305034 DOI: 10.1017/ice.2024.6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Affiliation(s)
- Daniel J Livorsi
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans' Affairs (VA) Health Care System, Iowa City, Iowa
- Division of Infectious Diseases, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Westyn Branch-Elliman
- VA Boston Healthcare System, Department of Medicine, Section of Infectious Diseases. Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Dimitri Drekonja
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Kelly L Echevarria
- VHA Pharmacy Benefits and Antimicrobial Stewardship Task Force, Department of Veterans' Affairs, Washington, DC
| | - Margaret A Fitzpatrick
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Healthcare System, Aurora, Colorado
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Matthew Bidwell Goetz
- VA Greater Los Angeles Healthcare System, Los Angeles, California
- David Geffen School of Medicine at the University of California, Los Angeles, California
| | - Christopher J Graber
- VA Greater Los Angeles Healthcare System, Los Angeles, California
- David Geffen School of Medicine at the University of California, Los Angeles, California
| | - Makoto M Jones
- Informatics, Decision Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Allison A Kelly
- VHA Pharmacy Benefits and Antimicrobial Stewardship Task Force, Department of Veterans' Affairs, Washington, DC
- Cincinnati Veterans' Affairs Medical Center, Cincinnati, Ohio
- University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Karl Madaras-Kelly
- Boise Veterans' Affairs Medical Center, Boise, Idaho
- Idaho State University, College of Pharmacy, Meridian, Idaho
| | - Daniel J Morgan
- Department of Medicine, VA Maryland Healthcare System, Baltimore, Maryland
- Center for Innovation in Diagnosis, University of Maryland School of Medicine, Baltimore, Maryland
| | - Vanessa W Stevens
- Informatics, Decision Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Katie Suda
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Barbara W Trautner
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey Veterans' Affairs Medical Center, Houston, Texas
- Section of Health Services Research, Baylor College of Medicine, Houston, Texas
| | - Michael J Ward
- Geriatric Research, Education, and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, Tennessee
- Department of Emergency Medicine and Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robin L P Jump
- Technology Enhancing Cognition and Health Geriatric Research Education and Clinical Center (TECH-GRECC) at the VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of Geriatric Medicine, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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10
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Bocquier A, Essilini A, Pereira O, Welter A, Pulcini C, Thilly N. Impact of a public commitment charter, a non-prescription pad and an antibiotic information leaflet to improve antibiotic prescription among general practitioners: A randomised controlled study. J Infect Public Health 2024; 17:217-225. [PMID: 38113819 DOI: 10.1016/j.jiph.2023.11.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 11/08/2023] [Accepted: 11/27/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND This study evaluated the effect of a multifaceted antibiotic stewardship intervention on the overall prescription of systemic antibiotics in primary care. Secondary objectives evaluated the effect on the prescription of broad-spectrum antibiotics and the seasonal variation of both total antibiotic and quinolone prescriptions, as a proxy for unnecessary prescribing. METHODS This pragmatic, randomised, controlled, before-after intervention study was conducted among general practitioners (GPs) who over prescribe antibiotics in Lorraine, France (Intervention group, n = 109; Control group, n = 236; Before period, 01/10/2017-30/09/2018; After period, 01/10/2018-30/09/2019). The intervention included a public commitment charter, a patient information leaflet and a non-prescription pad. Health Insurance data was obtained to calculate overall and broad-spectrum prescription rate (defined daily doses/1000 consultations) and the seasonal variation of prescriptions (%), by period. The intervention effect was measured with general linear mixed models including three independent variables (group, period and group x period interaction). RESULTS Overall, compared to the Before period, GPs in both groups prescribed significantly fewer systemic antibiotics (p < 0.001) and broad-spectrum antibiotics (p < 0.001) after the intervention was implemented. However, the group x period interaction did not show any evidence that the intervention had an effect on these outcomes. Nevertheless, the intervention did result in a trend towards less seasonal variation in total systemic antibiotic prescription (p = 0.052). CONCLUSIONS A tendency towards an effect of the intervention to reduce unnecessary antibiotic prescribing during winter months was observed. No effect was observed on the overall volume of systemic antibiotic prescription. This study invites discussion about the challenges faced when evaluating non-pharmacological interventions in primary care.
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Affiliation(s)
| | | | - Ouarda Pereira
- Direction Régionale du Service Médical du Grand Est, Nancy, France
| | - Adeline Welter
- Caisse Primaire d'Assurance Maladie du Bas Rhin, F-67000 Strasbourg, France
| | - Céline Pulcini
- Université de Lorraine, APEMAC, F-54000 Nancy, France; Université de Lorraine, CHRU-Nancy, Centre Régional en Antibiothérapie du Grand Est AntibioEst, F-54000 Nancy, France
| | - Nathalie Thilly
- Université de Lorraine, APEMAC, F-54000 Nancy, France; Université de Lorraine, CHRU-Nancy, Département Méthodologie, Promotion, Investigation, F-54000 Nancy, France
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11
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Jover-Sáenz A, Ramírez-Hidalgo M, Bellés Bellés A, Ribes Murillo E, Batlle Bosch M, Ribé Miró A, Mari López A, Cayado Cabanillas J, Piqué Palacín N, Garrido-Calvo S, Ortiz Valls M, Gracia Vilas MI, Gros Navés L, Javierre Caudevilla MJ, Montull Navarro L, Bañeres Argiles C, Vaqué Castilla P, Ichart Tomás JJ, Saura Codina M, Andreu Mayor E, Martorell Solé R, Vena Martínez A, Albalad Samper JM, Cano Marrón S, Soler Elcacho C, Rodríguez Garrocho A, Terrer Manrique G, Solé Curcó A, Escuin DDLR, Estadella Servalls MJ, Figueres Farreny AM, Montaña Esteban LM, Sanz Borrell L, Morales Valle A, Pallerola Planes M, Hamadi A, Pujol Aymerich F, Toribio Redondo F, Urgelés Castillón MC, Valgañon Palacios J, Olivart Parejo M, Torres-Puig-gros J. Effects of a Primary Care Antimicrobial Stewardship Program on Meticillin-Resistant Staphylococcus aureus Strains across a Region of Catalunya (Spain) over 5 Years. Antibiotics (Basel) 2024; 13:92. [PMID: 38247651 PMCID: PMC10812605 DOI: 10.3390/antibiotics13010092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 01/08/2024] [Accepted: 01/15/2024] [Indexed: 01/23/2024] Open
Abstract
Primary care antimicrobial stewardship program (ASP) interventions can reduce the over-prescription of unnecessary antibiotics, but the impact on the reduction in bacterial resistance is less known, and there is a lack of available data. We implemented a prolonged educational counseling ASP in a large regional outpatient setting to assess its feasibility and effectiveness. Over a 5-year post-implementation period, which was compared to a pre-intervention period, a significant reduction in antibiotic prescriptions occurred, particularly those associated with greater harmful effects and resistance selection. There was also a decrease in methicillin-resistant Staphylococcus aureus (MRSA) strains and in their co-resistance to other antibiotics, particularly those with an ecological impact.
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Affiliation(s)
- Alfredo Jover-Sáenz
- Unidad Territorial Infección Nosocomial (UTIN), Hospital Universitari Arnau de Vilanova de Lleida (HUAV), 25198 Lleida, Spain;
| | - María Ramírez-Hidalgo
- Unidad Territorial Infección Nosocomial (UTIN), Hospital Universitari Arnau de Vilanova de Lleida (HUAV), 25198 Lleida, Spain;
| | - Alba Bellés Bellés
- Sección de Microbiología, Hospital Universitari Arnau de Vilanova de Lleida (HUAV), 25198 Lleida, Spain;
| | - Esther Ribes Murillo
- Unidad de Farmacia de Atención Primaria, Institut Català de la Salut (ICS), 25007 Lleida, Spain;
| | - Meritxell Batlle Bosch
- Equipo de Atención Priamaria (EAP) Les Borges Blanques, 25400 Lleida, Spain; (M.B.B.); (A.R.M.)
| | - Anna Ribé Miró
- Equipo de Atención Priamaria (EAP) Les Borges Blanques, 25400 Lleida, Spain; (M.B.B.); (A.R.M.)
| | - Alba Mari López
- EAP Pla d’Urgell, 25001 Lleida, Spain; (A.M.L.); (J.C.C.); (N.P.P.)
| | | | | | | | | | | | | | | | | | | | | | - José Javier Ichart Tomás
- Servicio de Urgencias, Hospital Universitari Arnau de Vilanova de Lleida (HUAV), 25198 Lleida, Spain; (J.J.I.T.); (M.S.C.)
| | - Mireia Saura Codina
- Servicio de Urgencias, Hospital Universitari Arnau de Vilanova de Lleida (HUAV), 25198 Lleida, Spain; (J.J.I.T.); (M.S.C.)
| | | | | | - Ana Vena Martínez
- Servei de Geriatria, Hospital Universitari Santa Maria, 25198 Lleida, Spain;
| | | | - Susana Cano Marrón
- EAP Onze de Setembre, 25005 Lleida, Spain; (S.C.M.); (C.S.E.); (A.R.G.); (G.T.M.)
| | | | | | | | | | | | | | | | | | | | | | | | - Aly Hamadi
- EAP Balaguer, 25600 Lleida, Spain; (M.P.P.); (A.H.)
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12
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Kuruc Poje D, Kuharić M, Posavec Andrić A, Mađarić V, Poje JV, Payerl-Pal M, Tambić Andrašević A, Poje JM, Bačić Vrca V, Marušić S. Perspectives of primary care physicians on academic detailing for antimicrobial stewardship: feasibility and impact assessment. J Int Med Res 2024; 52:3000605231222242. [PMID: 38193298 PMCID: PMC10777789 DOI: 10.1177/03000605231222242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 12/06/2023] [Indexed: 01/10/2024] Open
Abstract
OBJECTIVE To understand primary care physicians' perspectives on academic detailing from an antimicrobial stewardship team to combat antibiotic overuse for upper respiratory infections and bronchitis in the COVID-19 era, which will help prevent avoidable outpatient visits. METHODS In this prospective study, 14 female Croatian physicians completed standardized qualitative interviews using a semi-structured guide. The data were analyzed using inductive methodology based on reflexive thematic analysis. We used a theoretically informed approach based on a conceptual framework of healthcare intervention implementability focused on three domains: acceptability, fidelity, and feasibility. RESULTS We identified six key themes highlighting barriers to changing prescribing practices, with patient pressure and specialist recommendations having an impact on the effectiveness of academic detailing. Despite challenges, primary care physicians described appreciation of direct interaction with evidence-based practices and reported usefulness, effectiveness, and further need for academic detailing. CONCLUSION This study highlights the complex dynamics involved in implementing healthcare interventions and provides valuable insights for enhancing strategies directed at improving antibiotic prescribing practices. Specifically, our findings emphasize factors influencing behavior changes in physicians' antibiotic prescribing. The authors advocate for a collaborative approach involving community and hospital-based professionals to provide tailored guidance and address questions, ultimately improving prescribing practices.
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Affiliation(s)
- Darija Kuruc Poje
- Department of Hospital Pharmacy, General Hospital “Dr. Tomislav Bardek,” Koprivnica, Croatia
| | - Maja Kuharić
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois Chicago, Chicago, IL, USA
| | | | - Vesna Mađarić
- Department of Pulmology and Infectology, General Hospital “Dr. Tomislav Bardek,” Koprivnica, Croatia
| | - Janeš Vlatka Poje
- Department of Clinical Microbiology, Institute of Public Health County Koprivničko-Križevačka, Koprivnica, Croatia
| | - Marina Payerl-Pal
- Department of Clinical Microbiology, Institute of Public Health County Međimurje, Čakovec, Croatia
| | - Arjana Tambić Andrašević
- Department of Clinical Microbiology, The University Hospital for Infectious Diseases, Zagreb, Croatia
- School of Dental Medicine, University of Zagreb, Zagreb, Croatia
| | - Juraj Mark Poje
- Department of Neurology, General Hospital “Dr. Tomislav Bardek,” Koprivnica, Croatia
| | - Vesna Bačić Vrca
- Department of Pharmacy, Clinical Hospital Dubrava, Zagreb, Croatia
- University of Zagreb, Faculty of Pharmacy and Biochemistry, Zagreb, Croatia
| | - Srećko Marušić
- Department of Endocrinology, Clinical Hospital Dubrava, Zagreb, Croatia
- University of Zagreb, School of Medicine, Zagreb, Croatia
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13
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Ruiz-Ramos J, Escolà-Vergé L, Monje-López ÁE, Herrera-Mateo S, Rivera A. The Interventions and Challenges of Antimicrobial Stewardship in the Emergency Department. Antibiotics (Basel) 2023; 12:1522. [PMID: 37887223 PMCID: PMC10604141 DOI: 10.3390/antibiotics12101522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 09/25/2023] [Accepted: 10/06/2023] [Indexed: 10/28/2023] Open
Abstract
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.
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Affiliation(s)
- Jesus Ruiz-Ramos
- Pharmacy Department, Hospital Santa Creu i Sant Pau, 08025 Barcelona, Spain;
- Sant Pau Institute of Biomedical Research (IIb Sant Pau), 08025 Barcelona, Spain (A.R.)
| | - Laura Escolà-Vergé
- Infectious Diseases Department, Hospital Santa Creu i Sant Pau, 08025 Barcelona, Spain;
- CIBERINFEC, ISCIII—CIBER, Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Álvaro Eloy Monje-López
- Pharmacy Department, Hospital Santa Creu i Sant Pau, 08025 Barcelona, Spain;
- Sant Pau Institute of Biomedical Research (IIb Sant Pau), 08025 Barcelona, Spain (A.R.)
| | - Sergio Herrera-Mateo
- Sant Pau Institute of Biomedical Research (IIb Sant Pau), 08025 Barcelona, Spain (A.R.)
- Emergency Department, Hospital Santa Creu i Sant Pau, 08025 Barcelona, Spain
| | - Alba Rivera
- Sant Pau Institute of Biomedical Research (IIb Sant Pau), 08025 Barcelona, Spain (A.R.)
- Microbiology Department, Hospital Santa Creu i Sant Pau, 08025 Barcelona, Spain
- Genetics and Microbiology Department, Universitat Autònoma de Barcelona, 08025 Barcelona, Spain
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14
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Carmichael H, Asch SM, Bendavid E. Clostridium difficile and other adverse events from overprescribed antibiotics for acute upper respiratory infection. J Intern Med 2023; 293:470-480. [PMID: 36460621 DOI: 10.1111/joim.13597] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
BACKGROUND Guidelines widely recommend avoiding antibiotics for many acute upper respiratory infections (aURIs) to avert adverse events in the absence of likely benefit. However, the extent of harm from these antibiotics remains a subject of debate and could inform patient-centered decision-making. Prior estimates finding a number needed to harm (NNH) between 8 and 10 rely on patient-reported adverse events of any severity. In this analysis, we sought to estimate adverse events by only measuring comparatively severe events that require subsequent clinical evaluation. METHODS We constructed a retrospective cohort, including 51 million patient encounters. Using logistic regression models, we determined the adjusted odds ratio (aOR) of clinically detectable adverse events following antibiotic use compared with events among unexposed individuals with aURIs. Our outcomes included candidiasis, diarrhea, Clostridium difficile infection (CDI), and a composite outcome. FINDINGS From our analysis, 62.4% of the population received antibiotics in an aURI encounter. Observed adverse events in the antibiotic-exposed group were 54,279 and 46,936 for diarrhea and candidiasis, respectively, yielding an aOR of 1.24 and 1.61, and an NNH of 3,126 and 1,975. Observed events of CDI in the exposed group were 30,133, and aORs of isolated CDI and combined adverse events were 1.07 and 1.30, resulting in an NNH of 17,695 and 1,150, respectively. Females were more likely to be diagnosed with any adverse event. Overall antibiotics were found to result in 5.7 additional cases of CDI per 100,000 outpatient prescriptions following an upper respiratory tract infection. INTERPRETATION Despite higher NNH than previous methods of analysis, we find substantial iatrogenic harm associated with prescribing antibiotics in aURIs.
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Affiliation(s)
- Harris Carmichael
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California, USA.,Intermountain Healthcare Delivery Institute, Intermountain Healthcare, Murray, Utah, USA.,Center for Health Policy, Center for Primary Care and Outcomes Research, Stanford University, Stanford, California, USA
| | - Steven M Asch
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California, USA.,Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California, USA
| | - Eran Bendavid
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California, USA.,Center for Health Policy, Center for Primary Care and Outcomes Research, Stanford University, Stanford, California, USA
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15
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Toghroli R, Aghamolaei T, Hassani L, Sharifi H, Jajarmi M. Determinants of antimicrobial resistance occurrence in animal‐based food, perceived by livestock farmers: A qualitative phenomenological study. Health Sci Rep 2023; 6:e1160. [PMID: 36970640 PMCID: PMC10031206 DOI: 10.1002/hsr2.1160] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 02/28/2023] [Accepted: 03/05/2023] [Indexed: 03/24/2023] Open
Abstract
Background and Purpose of the Study The determinants of antimicrobial resistance in human medicine have been copiously explored. On the other hand, the existing research in veterinary medicine and animal husbandry is in its infancy. The present qualitative study used the one‐health approach to explore farmers’ attitudes toward antimicrobial use and antimicrobial stewardship. Methodology The present qualitative study was phenomenological in type. It was conducted in 2022 in the two cities of Kerman and Bandar Abbas in Iran. The data were collected through in‐depth interviews by semistructured interviews with 17 livestock, poultry, and aquatic animal breeders selected through purposive sampling. The interviews lasted between 35 and 65 min in the Farsi language. The data were analyzed using conventional qualitative content analysis and Colaizzi's seven‐step analysis technique. Results The open coding was done in MAXQDA 10 and the results of data analysis were classified into five main themes and 17 subthemes subcategories. The main categories include personal determinants, contextual determinants, legal and regulatory determinants, social determinants, and economic determinants. Conclusion Considering the increasing use of antibiotics among livestock farmers and breeders of animals used as human food, different measures such as educational, regulatory, social, and even cultural interventions may be able to control and prevent antimicrobial resistance.
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Affiliation(s)
- Razie Toghroli
- Social Determinants in Health Promotion Research Center, Hormozgan Health instituteHormozgan University of Medical SciencesBandar AbbasIran
| | - Teamur Aghamolaei
- Social Determinants in Health Promotion Research Center, Hormozgan Health instituteHormozgan University of Medical SciencesBandar AbbasIran
| | - Laleh Hassani
- Social Determinants in Health Promotion Research Center, Hormozgan Health instituteHormozgan University of Medical SciencesBandar AbbasIran
| | - Hamid Sharifi
- HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in HealthKerman University of Medical SciencesKermanIran
| | - Maziar Jajarmi
- Department of Pathobiology, Faculty of Veterinary MedicineShahid Bahonar University of KermanKermanIran
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16
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Andrews SL, Gravely AA, Beaudoin A, Rothenberger MK, Drekonja DM. Decreased antimicrobial prescribing rate following academic detailing of resident physicians in outpatient clinic. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e61. [PMID: 37113203 PMCID: PMC10127236 DOI: 10.1017/ash.2022.259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 06/06/2022] [Accepted: 06/07/2022] [Indexed: 04/29/2023]
Abstract
Among 37 internal-medicine resident physicians assigned to our outpatient clinic at Minneapolis Veterans' Affairs Health Care System (MVAHCS) on July 1, 2017, we designed a pre- and postintervention observational study. Our results show that in-person academic detailing around outpatient antimicrobial selection was associated with a decrease in outpatient antimicrobial prescriptions in a group of high-prescribing resident physicians.
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Affiliation(s)
- Shannon L. Andrews
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
- Author for correspondence: Shannon L. Andrews, Pediatric Infectious Diseases, Academic Office Building, AO-103, 2450 Riverside Ave S, MinneapolisMN55454. E-mail:
| | - Amy A. Gravely
- Minneapolis Veterans’ Affairs Health Care System, Minneapolis, Minnesota
| | - Amanda Beaudoin
- One Health Antibiotic Stewardship, Minnesota Department of Health, St. Paul, Minnesota
| | - Meghan K. Rothenberger
- Infectious Disease Section, Minneapolis VA Health Care System, Minneapolis, Minnesota
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Dimitri M. Drekonja
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
- Chief, Infectious Disease Section, Minneapolis Veterans’ Affairs Health Care System, Minneapolis
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17
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Otake S, Kusama Y, Tsuzuki S, Myojin S, Kimura M, Kamiyoshi N, Takumi T, Ishida A, Kasai M. Comparing the effects of antimicrobial stewardship at primary emergency centers. Pediatr Int 2023; 65:e15614. [PMID: 37658628 DOI: 10.1111/ped.15614] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 06/24/2023] [Accepted: 06/30/2023] [Indexed: 09/03/2023]
Abstract
BACKGROUND Antimicrobial prescription rates tend to be high in outpatient settings and Primary Emergency Medical Centers (PECs) in Japan encounter difficulties in implementing antimicrobial stewardship programs (ASPs). While a nudge-based ASP publishing monthly newsletters reduces inappropriate prescription of oral third-generation cephalosporins (3GCs), which requires considerable effort. Therefore, developing more preferable ASP models in PECs is essential. METHODS We conducted a three-center, retrospective observational study. Himeji City Emergency Medical Center (Site A) introduced a facility-specific guideline for antimicrobial stewardship with reference to national guidelines. The Kobe Children's Primary Emergency Medical Center (Site B) provided the results of monitoring antibiotics prescription in a monthly newsletter. The Hanshin-Kita Children's First-Aid Center (Site C) did not perform a specific ASP. Prescription rates for 3GCs were categorized into pre- and post-intervention and compared using Poisson regression analysis. The difference-in-difference method was used to assess the effect of these interventions. RESULTS The numbers of patients pre- and post- intervention were 177,126 and 91,251, respectively. The 3GCs prescription rate at Site A, Site B, and Site C decreased from 6.7%, 4.2%, and 6.1% in 2016 to 2.3%, 1.0%, and 2.0% in 2019, respectively. Site B had a greater reduction than Site A and Site C (relative risk [RR] 0.71 [95% confidence interval (CI): 0.62-0.82]; p < 0.001, RR 0.71, [95% CI: 0.62-0.81]; p < 0.001). There was no significant difference between Site A and Site C (RR 1.00 [95% CI 0.88-1.13]; p = 0.963). CONCLUSION A facility-specific guideline was less effective than a nudge-based ASP for decreasing oral 3GC prescriptions in PECs.
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Affiliation(s)
- Shogo Otake
- Division of Infectious Disease, Department of Pediatrics, Kobe Children's Hospital, Kobe, Hyogo, Japan
| | - Yoshiki Kusama
- Department of Pediatrics, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Hyogo, Japan
- AMR Clinical Reference Center, Disease Control and Prevention Center, National Center for Global Health and Medicine Hospital, Tokyo, Japan
| | - Shinya Tsuzuki
- AMR Clinical Reference Center, Disease Control and Prevention Center, National Center for Global Health and Medicine Hospital, Tokyo, Japan
| | - Shota Myojin
- Division of Infectious Diseases, National Center for Child Health and Development, Tokyo, Japan
| | - Makoto Kimura
- Department of Pharmacy, Kobe Children's Primary Emergency Medical Center, Kobe, Hyogo, Japan
| | - Naohiro Kamiyoshi
- Department of Pediatrics, Red Cross Society Himeji Hospital, Himeji, Hyogo, Japan
| | - Toru Takumi
- Hanshin-Kita Children's First-Aid Center, Itami, Hyogo, Japan
| | - Akihito Ishida
- Kobe Children's Primary Emergency Medical Center, Kobe, Hyogo, Japan
| | - Masashi Kasai
- Division of Infectious Disease, Department of Pediatrics, Kobe Children's Hospital, Kobe, Hyogo, Japan
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18
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Impact of a Primary Care Antimicrobial Stewardship Program on Bacterial Resistance Control and Ecological Imprint in Urinary Tract Infections. Antibiotics (Basel) 2022; 11:antibiotics11121776. [PMID: 36551433 PMCID: PMC9774161 DOI: 10.3390/antibiotics11121776] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 11/09/2022] [Accepted: 12/05/2022] [Indexed: 12/13/2022] Open
Abstract
Antimicrobial stewardship programs (ASPs) are a central component in reducing the overprescription of unnecessary antibiotics, with multiple studies showing benefits in the reduction of bacterial resistance. Less commonly, ASPs have been performed in outpatient settings, but there is a lack of available data in these settings. We implemented an ASP in a large regional outpatient setting to assess its feasibility and effectiveness. Over a 5-year post-implementation period, compared to the pre-intervention period, a significant reduction in antibiotic prescription occurred, with a reduction in resistance in E. coli urinary isolates. ASP activities also were found to be cost-effective, with a reduction in medication prescription.
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19
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A retrospective review of antibiotic use for acute respiratory infections in urgent-care patients. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2022; 2:e189. [PMID: 36505944 PMCID: PMC9727505 DOI: 10.1017/ash.2022.337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 10/20/2022] [Accepted: 10/22/2022] [Indexed: 12/09/2022]
Abstract
Objective We examined the use of antibiotics for acute respiratory infections in an urgent-care setting. Design Retrospective database review. Setting The study was conducted in 2 urgent-care clinics staffed by academic emergency physicians in San Diego, California. Patients Visits for acute respiratory infections were identified based on presenting complaints. Methods The primary outcome was a discharge prescription for an antibiotic. The patient and provider characteristics that predicted this outcome were analyzed using logistic regression. The variation in antibiotic prescriptions between providers was also analyzed. Results In total, 15,160 visits were analyzed. The patient characteristics were not predictive of antibiotic treatment. Physicians were more likely than advanced practice practitioners to prescribe antibiotics (1.31; 95% confidence interval [CI], 1.21-1.42). For every year of seniority, a provider was 1.03 (95% CI, 1.02-1.03) more likely to prescribe an antibiotic. Although the providers saw similar patients, we detected significant variation in the antibiotic prescription rate between providers: the mean antibiotic prescription rate within the top quartile was 54.3% and the mean rate in the bottom quartile was 21.7%. Conclusions The patient and provider characteristics we examined were either not predictive or were only weakly predictive of receiving an antibiotic prescription for acute respiratory infection. However, we detected a marked variation between providers in the rate of antibiotic prescription. Provider differences, not patient differences, drive variations in antibiotic prescriptions. Stewardship efforts may be more effective if directed at providers rather than patients.
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Essilini A, Le Dref G, Bocquier A, Kivits J, Welter A, Pulcini C, Thilly N. French general practitioners’ and patients’ acceptability of a public commitment charter and patient information leaflets targeting unnecessary antibiotic use: a qualitative study. Antimicrob Resist Infect Control 2022; 11:32. [PMID: 35135624 PMCID: PMC8822724 DOI: 10.1186/s13756-022-01065-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 01/11/2022] [Indexed: 11/28/2022] Open
Abstract
Background The ‘AntibioCharte’ randomised controlled study aimed at assessing the impact of a multifaceted antibiotic stewardship intervention targeting French general practitioners with higher-than-average antibiotic use. The intervention included a public commitment charter signed by the general practitioner, a non-prescription pad, and a patient information leaflet. Objectives We conducted a qualitative study to evaluate general practitioners’ fidelity in the intervention and its acceptability by patients and general practitioners. Methods This investigation was performed in northeastern France from July 2019 to May 2020, among the AntibioCharte intervention group after a 1-year implementation period. General practitioners’ fidelity in the charter was assessed by direct observations; general practitioners’ fidelity in the other tools, and acceptability of both general practitioners and patients were assessed through semi-structured face-to-face individual interviews. Results Twenty-seven general practitioners and 14 patients participated. General practitioners’ fidelity varied according to the tool: the charter was clearly displayed in most waiting rooms; the non-prescription pad was used throughout the intervention period by most general practitioners while the leaflet was used by fewer general practitioners. Both general practitioners and patients found the charter’s content and form relevant, but few general practitioners felt themselves publicly engaged. The waiting room may not be appropriate to display the charter as some general practitioners forgot it and patients did not always read the displayed documents. General practitioners appreciated the pad and found that it could help them change their practices. It was perceived as a good tool to educate patients and manage their expectations for antibiotics. Patients appreciated the pad too, especially information on the infections’ symptoms and their duration. Still, some patients feared that it could encourage doctors not to prescribe antibiotics. Unlike general practitioners, who considered the leaflet redundant with the information given during the consultation, patients found it useful to raise awareness on antibiotics’ specificities and risks, and remind them of good practices. Conclusions The AntibioCharte intervention was overall well accepted by general practitioners and patients. The non-prescription pad was the best perceived tool. Trial registration number ClinicalTrials.gov: NCT04562571. Supplementary Information The online version contains supplementary material available at 10.1186/s13756-022-01065-3.
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Effects of social norm feedback on antibiotic prescribing and its characteristics in behaviour change techniques: a mixed-methods systematic review. THE LANCET INFECTIOUS DISEASES 2022; 23:e175-e184. [PMID: 36521504 DOI: 10.1016/s1473-3099(22)00720-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 09/28/2022] [Accepted: 10/13/2022] [Indexed: 12/15/2022]
Abstract
Low-cost and low-barrier antibiotic stewardship strategies are urgently needed to deal with the widespread problem of antibiotic resistance. Social norm feedback could be a promising strategy. In this mixed-methods systematic review (PROSPERO: CRD42022361039), we aimed to identify the key behaviour change techniques used in social norm feedback for antibiotic stewardship and assess their effectiveness in reducing antibiotic prescribing. We searched PubMed, Embase, Web of Science, and Scopus for peer-reviewed studies published between Jan 1, 2000, and Jan 20, 2022. 3547 studies were screened, of which 23 studies reporting the effects of social norm feedback interventions on antibiotic prescribing met the inclusion criteria. 19 behaviour change techniques were tested in the included studies. The meta-analyses showed that social norm feedback is an effective strategy for reducing antibiotic prescribing, with an overall rate difference of 4% (p<0·0001). The behaviour change technique with the highest effective ratio (ER=13) was information about health consequences, followed by instruction on how to perform the behaviour (ER=9) and adding objects to the environment (ER=9). Social norm feedback is a promising strategy to reduce antibiotic prescribing, and can be incorporated into the clinical decision-making support system.
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Cox S, Lo-A-Foe K, van Hoof M, Dinant GJ, Oudhuis G, Savelkoul P, Cals J, de Bont E. Physician-Targeted Interventions in Antibiotic Prescribing for Urinary Tract Infections in General Practice: A Systematic Review. Antibiotics (Basel) 2022; 11:1560. [PMID: 36358215 PMCID: PMC9686805 DOI: 10.3390/antibiotics11111560] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 10/25/2022] [Accepted: 11/03/2022] [Indexed: 07/30/2023] Open
Abstract
Urinary tract infections (UTIs) are the most common reason for women to consult a general practitioner (GP). While UTIs are self-limiting in half of cases, most women are prescribed antibiotics, often in discordance with established guidelines. Researchers have employed different interventions to improve GPs' prescribing behavior, especially for respiratory infections, but it is uncertain whether these are effective for UTI care. Therefore, we performed a systematic review, including (cluster) randomized clinical trials investigating the effect of interventions targeted at GPs to improve antibiotic prescriptions for UTI. From September to December 2021 we searched the Medline, Web of Science, and CENTRAL databases, ultimately including ten studies describing eleven trials. We determined the effect of the interventions on the decision to prescribe and on the choice of antibiotic. Results showed that most studies employed multifaceted interventions, most frequently including audit & feedback and/or educational meetings. Seven out of nine trials that recorded first-choice prescriptions saw an increased proportion of first-choice antibiotics in the intervention groups compared to control groups. The employed interventions also caused a decreased proportion of at least one broad-spectrum antibiotic in five out of six studies that measured broad-spectrum antibiotic prescriptions. However, the total number of antibiotic prescriptions for UTIs increased in four out of eight studies. Therefore, while effective at influencing GPs' prescribing behavior, future interventions should also focus on improving the decision to prescribe at all.
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Affiliation(s)
- Stefan Cox
- Department of Family Medicine, Maastricht University, P. Debyeplein 1, 6229 HA Maastricht, The Netherlands
| | - Kelly Lo-A-Foe
- Department of Family Medicine, Maastricht University, P. Debyeplein 1, 6229 HA Maastricht, The Netherlands
| | - Minke van Hoof
- Department of Family Medicine, Maastricht University, P. Debyeplein 1, 6229 HA Maastricht, The Netherlands
| | - Geert-Jan Dinant
- Department of Family Medicine, Maastricht University, P. Debyeplein 1, 6229 HA Maastricht, The Netherlands
| | - Guy Oudhuis
- Department of Medical Microbiology, Maastricht University Medical Centre+, Universiteitssingel 40, 6229 ER Maastricht, The Netherlands
| | - Paul Savelkoul
- Department of Medical Microbiology, Maastricht University Medical Centre+, Universiteitssingel 40, 6229 ER Maastricht, The Netherlands
| | - Jochen Cals
- Department of Family Medicine, Maastricht University, P. Debyeplein 1, 6229 HA Maastricht, The Netherlands
| | - Eefje de Bont
- Department of Family Medicine, Maastricht University, P. Debyeplein 1, 6229 HA Maastricht, The Netherlands
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Improved management of cystitis in primary care following the implementation of a simple multifaceted intervention. Aten Primaria 2022; 54:102493. [PMID: 36270205 PMCID: PMC9586853 DOI: 10.1016/j.aprim.2022.102493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 09/19/2022] [Accepted: 09/27/2022] [Indexed: 11/21/2022] Open
Abstract
Objective We assessed the impact of the implementation of a simple multifaceted intervention aimed at improving management of cystitis in primary care. Design Quality control before and after study. Site Primary care centres in Barcelona city provided by the Catalonian Institute of Health. Participants The multifaceted intervention consisted of (1) creation of a group with a leader in each of the primary care centres, out of hours services, sexual and reproductive centres, and home visit service, (2) session on management of cystitis in each centre, (3) result feedback for professionals, and (4) provision of infographics for professionals and patients with urinary tract infections. Interventions started in November 2020 and ended in the summer of 2021. Main measurements Variation in the prescription of first-line antibiotics, usage of antibiotics, and request for urine cultures before and after this intervention. Results Training sessions took place in 93% of the centres. The use of first-line therapies cystitis increased by 6.4% after the intervention (95% confidence interval [CI], 5.7–7.1%). The use of nitrofurantoin in recurrent cystitis increased, mainly in out of hours service (8.7%; 95% CI, 5.2–12.2%). Urine cultures were more frequently requested after the intervention for recurrent cystitis in both primary care centres and out of hours services, with a 7.2% increase [95% CI, 5.9–8.5%), but also for uncomplicated urinary tract infections (3.1%; 95% CI, 1.8–4.4%). Conclusions A low-intensity multifaceted intervention on management of cystitis, with strong institutional support, resulted in a better choice of antibiotic in antibiotic prescribing, but the intervention had less impact on the adequacy of urine cultures.
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Löffler C, Buuck T, Iwen J, Schulz M, Zapf A, Kropp P, Wollny A, Krause L, Müller B, Ozga AK, Goldschmidt E, Altiner A. Promoting rational antibiotic therapy among high antibiotic prescribers in German primary care-study protocol of the ElektRA 4-arm cluster-randomized controlled trial. Implement Sci 2022; 17:69. [PMID: 36195897 PMCID: PMC9530431 DOI: 10.1186/s13012-022-01241-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 09/21/2022] [Indexed: 11/15/2022] Open
Abstract
Background The rational use of antibiotics is of great importance in health care. In primary care, acute respiratory infections are the most common cause of inappropriate antibiotic prescribing. Since existing studies aiming to optimize antibiotic use are usually based on the voluntary participation of physicians, general practitioners (GPs) with inappropriate prescribing behavior are underrepresented. For the first time in Germany, the ElektRA study will assess and compare the effects of three interventions on antibiotic prescribing rates for respiratory and urinary tract infections among high prescribers in primary care. Method ElektRA is a 4-arm cluster-randomized controlled trial among German GPs in nine regional Associations of Statutory Health Insurance Physicians. On their behalf, the Central Research Institute of Ambulatory Health Care in Germany (Zi) analyses all outpatient claims and prescription data. Based on this database, high antibiotic prescribing GPs are identified and randomized into four groups: a control group (N=2000) and three intervention arms. We test social norm feedback on antibiotic prescribing (N=2000), social norm feedback plus online training on rational prescribing practice and communication strategies (N=2000), and social norm feedback plus online peer-moderated training on rational antibiotic prescribing, communication strategies, and sustainable behavior change (N=1250). The primary outcome is the overall rate of antibiotic prescriptions. Outcomes are measured before intervention (T0, October 2020–September 2022) and over a period of 15 months (T1, October 2022 to December 2023) after randomization. Discussion The aim of the study is to implement individualized, low-threshold interventions to reduce antibiotic prescribing among high prescribers in primary care. If successful, a change in behavior among otherwise difficult-to-reach high prescribers will directly improve patient care. The increase in quality of care will ideally be achieved both in terms of the quantity of antibiotics used as well as the kind of substances prescribed. Also, if effective strategies for high prescribers are identified through this study, they can be applied not only to the antibiotics addressed in this study, but also to other areas of prescription management. Trial registration Current Controlled Trials ISRCTN95468513. Supplementary Information The online version contains supplementary material available at 10.1186/s13012-022-01241-4.
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Affiliation(s)
- Christin Löffler
- Institute of General Practice, Rostock University Medical Center, Postbox 100888, 18055, Rostock, Germany.
| | - Theresa Buuck
- Institute of General Practice, Rostock University Medical Center, Postbox 100888, 18055, Rostock, Germany
| | - Julia Iwen
- Association of Substitute Health Funds (Vdek) e.V, Berlin, Germany
| | - Maike Schulz
- Central Research Institute of Ambulatory Health Care in Germany (Zi), Berlin, Germany
| | - Antonia Zapf
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Kropp
- Institute of Medical Psychology and Medical Sociology, Rostock University Medical Center, Rostock, Germany
| | - Anja Wollny
- Institute of General Practice, Rostock University Medical Center, Postbox 100888, 18055, Rostock, Germany
| | - Linda Krause
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Britta Müller
- Institute of Medical Psychology and Medical Sociology, Rostock University Medical Center, Rostock, Germany
| | - Ann-Katrin Ozga
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Attila Altiner
- Institute of General Practice, Rostock University Medical Center, Postbox 100888, 18055, Rostock, Germany
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25
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Lautenbach E, Hamilton KW, Grundmeier R, Neuhauser MM, Hicks LA, Jaskowiak-Barr A, Cressman L, James T, Omorogbe J, Frager N, Menon M, Kratz E, Dutcher L, Chiotos K, Gerber JS. Development of an Electronic Algorithm to Target Outpatient Antimicrobial Stewardship Efforts for Acute Bronchitis and Pharyngitis. Open Forum Infect Dis 2022; 9:ofac273. [PMID: 35854991 PMCID: PMC9291392 DOI: 10.1093/ofid/ofac273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 05/28/2022] [Indexed: 11/17/2022] Open
Abstract
Background A major challenge for antibiotic stewardship programs is the lack of accurate and accessible electronic data to target interventions. We developed and validated separate electronic algorithms to identify inappropriate antibiotic use for adult outpatients with bronchitis and pharyngitis. Methods We used International Classification of Diseases, 10th Revision, diagnostic codes to identify patient encounters for acute bronchitis and pharyngitis at outpatient practices between 3/15/17 and 3/14/18. Exclusion criteria included immunocompromising conditions, complex chronic conditions, and concurrent infections. We randomly selected 300 eligible subjects each with bronchitis and pharyngitis. Inappropriate antibiotic use based on chart review served as the gold standard for assessment of the electronic algorithm, which was constructed using only data in the electronic data warehouse. Criteria for appropriate prescribing, choice of antibiotic, and duration were based on established guidelines. Results Of 300 subjects with bronchitis, 167 (55.7%) received an antibiotic inappropriately based on chart review. The electronic algorithm demonstrated 100% sensitivity and 95.3% specificity for detection of inappropriate prescribing. Of 300 subjects with pharyngitis, 94 (31.3%) had an incorrect prescribing decision. Among 29 subjects with a positive rapid streptococcal antigen test, 27 (93.1%) received an appropriate antibiotic and 29 (100%) received the correct duration. The electronic algorithm demonstrated very high sensitivity and specificity for all outcomes. Conclusions Inappropriate antibiotic prescribing for bronchitis and pharyngitis is common. Electronic algorithms for identifying inappropriate prescribing, antibiotic choice, and duration showed excellent test characteristics. These algorithms could be used to efficiently assess prescribing among practices and individual clinicians. Interventions based on these algorithms should be tested in future work.
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Affiliation(s)
- Ebbing Lautenbach
- Correspondence: Ebbing Lautenbach, MD, MPH, MSCE, Perelman School of Medicine, University of Pennsylvania, 712 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104-6073 ()
| | - Keith W Hamilton
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Robert Grundmeier
- Division of General Pediatrics, Department of Pediatrics, Children’s Hospital of Philadelphia (CHOP), Philadelphia, Pennsylvania, USA
| | - Melinda M Neuhauser
- Office of Antibiotic Stewardship, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA
| | - Lauri A Hicks
- Office of Antibiotic Stewardship, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA
| | - Anne Jaskowiak-Barr
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Leigh Cressman
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Tony James
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jacqueline Omorogbe
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nicole Frager
- Division of Infectious Diseases, Department of Pediatrics, Children’s Hospital of Philadelphia (CHOP), Philadelphia, Pennsylvania, USA
| | - Muida Menon
- Division of Infectious Diseases, Department of Pediatrics, Children’s Hospital of Philadelphia (CHOP), Philadelphia, Pennsylvania, USA
| | - Ellen Kratz
- Division of Infectious Diseases, Department of Pediatrics, Children’s Hospital of Philadelphia (CHOP), Philadelphia, Pennsylvania, USA
| | - Lauren Dutcher
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kathleen Chiotos
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA,Division of Infectious Diseases, Department of Pediatrics, Children’s Hospital of Philadelphia (CHOP), Philadelphia, Pennsylvania, USA
| | - Jeffrey S Gerber
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA,Division of Infectious Diseases, Department of Pediatrics, Children’s Hospital of Philadelphia (CHOP), Philadelphia, Pennsylvania, USA
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26
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Taylor MG, Palazzi DL. Antimicrobial Stewardship in the Pediatric Primary Care Setting. Pediatr Ann 2022; 51:e196-e201. [PMID: 35575544 DOI: 10.3928/19382359-20220315-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Antibiotics are the most commonly prescribed medications in the pediatric outpatient setting, yet 30% to 50% of these prescriptions are deemed to be unnecessary. Outpatient antimicrobial stewardship is the concerted effort to monitor and improve antibiotic use in the community setting. The best methods of conducting antimicrobial stewardship in the outpatient setting are currently unknown, and an individualized approach is likely needed. In this review, we discuss the importance of, resources for, and research supporting outpatient antimicrobial stewardship and review ways an individual pediatric provider can further steward efforts. [Pediatr Ann. 2022;51(5):e196-e201.].
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Poole NM, Frost H. Targets and Methods to Improve Outpatient Antibiotic Prescribing for Pediatric Patients. Infect Dis Clin North Am 2022; 36:187-202. [DOI: 10.1016/j.idc.2021.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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28
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Funaro JR, Moehring RW, Liu B, Lee HJ, Yang S, Sarubbi CB, Anderson DJ, Wrenn RH. Impact of Education and Data Feedback on Guideline-Concordant Prescribing for Urinary Tract Infections in the Outpatient Setting. Open Forum Infect Dis 2022; 9:ofab214. [PMID: 35146036 PMCID: PMC8825625 DOI: 10.1093/ofid/ofab214] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 04/26/2021] [Indexed: 01/09/2023] Open
Abstract
Background Urinary tract infections (UTIs) are the most common outpatient indication for antibiotics and an important target for antimicrobial stewardship (AS) activities. With The Joint Commission standards now requiring outpatient AS, data supporting effective strategies are needed. Methods We conducted a 2-phase, prospective, quasi-experimental study to estimate the effect of an outpatient AS intervention on guideline-concordant antibiotic prescribing in a primary care (PC) clinic and an urgent care (UC) clinic between August 2017 and July 2019. Phase 1 of the intervention included the development of clinic-specific antibiograms and UTI diagnosis and treatment guidelines, presented during educational sessions with clinic providers. Phase 2, consisting of routine clinic- and provider-specific feedback, began ~12 months after the initial education. The primary outcome was percentage of encounters with first- or second-line antibiotics prescribed according to clinic-specific guidelines and was assessed using an interrupted time series approach. Results Data were collected on 4724 distinct patients seen during 6318 UTI encounters. The percentage of guideline-concordant prescribing increased by 22% (95% CI, 12% to 32%) after Phase 1 education, but decreased by 0.5% every 2 weeks afterwards (95% CI, –0.9% to 0%). Following routine data feedback in Phase 2, guideline concordance stabilized, and significant further decline was not seen (–0.6%; 95% CI, –1.6% to 0.4%). This shift in prescribing patterns resulted in a 52% decrease in fluoroquinolone use. Conclusions Clinicians increased guideline-concordant prescribing, reduced UTI diagnoses, and limited use of high-collateral damage agents following this outpatient AS intervention. Routine data feedback was effective to maintain the response to the initial education.
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Affiliation(s)
- Jason R Funaro
- Department of Pharmacy, Duke University Medical Center, Durham, North Carolina, USA
| | - Rebekah W Moehring
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
| | - Beiyu Liu
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina, USA
| | - Hui-Jie Lee
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina, USA
| | - Siyun Yang
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina, USA
| | - Christina B Sarubbi
- Department of Pharmacy, Duke University Medical Center, Durham, North Carolina, USA.,Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
| | - Deverick J Anderson
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
| | - Rebekah H Wrenn
- Department of Pharmacy, Duke University Medical Center, Durham, North Carolina, USA.,Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
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Araújo BCD, Melo RCD, Bortoli MCD, Bonfim JRDA, Toma TS. Prevenção e controle de resistência aos antimicrobianos na Atenção Primária à Saúde: evidências para políticas. CIENCIA & SAUDE COLETIVA 2022; 27:299-314. [DOI: 10.1590/1413-81232022271.22202020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 11/18/2020] [Indexed: 11/21/2022] Open
Abstract
Resumo A resistência aos antimicrobianos é um problema mundial que põe em risco a segurança da saúde da população. O objetivo deste artigo é identificar e avaliar estratégias para prevenção e controle de resistência microbiana, bem como barreiras para sua implementação em serviços de Atenção Primária à Saúde (APS). Realizou-se uma síntese de evidências para políticas. As buscas de evidências foram realizadas entre novembro/dezembro de 2018, em 13 bases de dados. Um diálogo deliberativo foi realizado para validação dos resultados e levantamento de barreiras e facilitadores para implementação das estratégias. As 13 revisões sistemáticas incluídas mostraram que intervenções com foco em educação, uso de sistemas eletrônicos e biomarcadores reduziram o consumo e prescrição de antimicrobianos. É um obstáculo à implementação a expectativa de usuários/cuidadores em receber prescrição de antibióticos, e são facilitadores as ações educativas que envolvem profissionais de saúde. O uso racional de medicamentos se impõe na APS com vistas à prevenção da resistência dos microrganismos aos antibióticos. As intervenções identificadas neste estudo podem ser implementadas isoladamente ou em conjunto, conforme o contexto local.
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Saha SK, Kong DCM, Mazza D, Thursky K. A systems thinking approach for antimicrobial stewardship in primary care. Expert Rev Anti Infect Ther 2021; 20:819-827. [PMID: 34968161 DOI: 10.1080/14787210.2022.2023010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION The establishment of antimicrobial stewardship (AMS) in primary care is central to substantially reduce the antimicrobial use and the associated risk of resistance. This perspective piece highlights the importance of systems thinking to set up and facilitate AMS programs in primary care. AREAS COVERED The challenges that primary care faces to incorporate AMS programmes is multifactorial: an implementation framework, relevant resources, team composition, and system structures remain under-researched, and these issues are often overlooked and/or neglected in most parts of the world. Progress in the field remains slow in developed countries but potentially limited in low- and middle-income countries. EXPERT OPINION The key AMS strategies to optimize antimicrobial use in primary care are increasingly known; however, health system components that impact effective implementation of AMS programs remain unclear. We highlight the importance of systems thinking to identify and understand the resource arrangements, system structures, dynamic system behaviors, and intra- and interprofessional connections to optimally design and implement AMS programs in primary care. An AMS systems thinking systemigram (i.e. a visual representation of overall architecture of a system) could be a useful tool to foster AMS implementation in primary care.
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Affiliation(s)
- Sajal K Saha
- Department of General Practice, The School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,National Centre for Antimicrobial Stewardship (NCAS), Department of Infectious Diseases, Melbourne Medical School, University of Melbourne, Melbourne, Victoria, Australia.,Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Ellengowan Drive, Darwin, Australia
| | - David C M Kong
- National Centre for Antimicrobial Stewardship (NCAS), Department of Infectious Diseases, Melbourne Medical School, University of Melbourne, Melbourne, Victoria, Australia.,Centre for Medicine Use and Safety, Monash University, Victoria, Australia.,Pharmacy Department, Ballarat Health Services, Ballarat, Victoria, Australia
| | - Danielle Mazza
- Department of General Practice, The School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,National Centre for Antimicrobial Stewardship (NCAS), Department of Infectious Diseases, Melbourne Medical School, University of Melbourne, Melbourne, Victoria, Australia
| | - Karin Thursky
- National Centre for Antimicrobial Stewardship (NCAS), Department of Infectious Diseases, Melbourne Medical School, University of Melbourne, Melbourne, Victoria, Australia
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31
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Mortrude GC, Rehs MT, Sherman KA, Gundacker ND, Dysart CE. Implementation of Veterans Affairs Primary Care Antimicrobial Stewardship Interventions For Asymptomatic Bacteriuria And Acute Respiratory Infections. Open Forum Infect Dis 2021; 8:ofab449. [PMID: 34909435 PMCID: PMC8665674 DOI: 10.1093/ofid/ofab449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 08/31/2021] [Indexed: 11/14/2022] Open
Abstract
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.
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Affiliation(s)
- Grace C Mortrude
- Infectious Diseases Service Pharmacy, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin, USA
| | - Mary T Rehs
- Primary Care, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin, USA
| | - Katherine A Sherman
- Research Division, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin, USA
| | - Nathan D Gundacker
- Infectious Diseases, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin, USA.,Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Claire E Dysart
- Infectious Diseases Service Pharmacy, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin, USA
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Goebel MC, Trautner BW, Grigoryan L. The Five Ds of Outpatient Antibiotic Stewardship for Urinary Tract Infections. Clin Microbiol Rev 2021; 34:e0000320. [PMID: 34431702 PMCID: PMC8404614 DOI: 10.1128/cmr.00003-20] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Urinary tract infections (UTI) are one of the most common indications for antibiotic prescriptions in the outpatient setting. Given rising rates of antibiotic resistance among uropathogens, antibiotic stewardship is critically needed to improve outpatient antibiotic use, including in outpatient clinics (primary care and specialty clinics) and emergency departments. Outpatient clinics are in general a neglected practice area in antibiotic stewardship programs, yet most antibiotic use in the United States is in the outpatient setting. This article provides a comprehensive review of antibiotic stewardship strategies for outpatient UTI in the adult population, with a focus on the "five Ds" of stewardship for UTI, including right diagnosis, right drug, right dose, right duration, and de-escalation. Stewardship interventions that have shown success for improving prescribing for outpatient UTI are discussed, including diagnostic stewardship strategies, such as reflex urine cultures, computerized decision support systems, and modified reporting of urine culture results. Among the many challenges to achieving stewardship for UTI in the outpatient setting, some of the most important are diagnostic uncertainty, increasing antibiotic resistance, limitations of guidelines, and time constraints of stewardship personnel and front-line providers. This article presents a stewardship framework, built on current evidence and expert opinion, that clinicians can use to guide their own outpatient management of UTI.
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Affiliation(s)
- Melanie C. Goebel
- Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Barbara W. Trautner
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Larissa Grigoryan
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, Texas, USA
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Martinez-Sobalvarro JV, Júnior AAP, Pereira LB, Baldoni AO, Ceron CS, Dos Reis TM. Antimicrobial stewardship for surgical antibiotic prophylaxis and surgical site infections: a systematic review. Int J Clin Pharm 2021; 44:301-319. [PMID: 34843035 DOI: 10.1007/s11096-021-01358-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 11/16/2021] [Indexed: 12/26/2022]
Abstract
Background Surgical site infections account for 14-17% of all healthcare-associated infections. Antimicrobial stewardship (AMS) are complementary strategies developed to optimize the use of antimicrobials. Aim to evaluate the effectiveness of AMS in promoting adherence to surgical antibiotic prophylaxis protocols in hospitalized patients, reducing surgical site infection rate and cost-benefit ratio. Method This systematic review of randomized clinical trials, non-randomized clinical trials and before and after studies was performed using Pubmed, Cochrane, Web of Science, Scopus, Embase, Google Scholar and ClinicalTrials.gov, in addition to reference lists of included studies. The risk of bias of studies was measured by the ROBINS-I checklist and the quality of the evidence synthesis by GRADE. Results Fourteen before and after design studies were included. In 85.7% of the studies, AMS was effective in increasing adherence to surgical antibiotic prophylaxis protocols and in 28.5%, there was reduction in surgical site infection rate. Three studies evaluated cost-benefit ratio and found a favorable impact. Eight (57%) studies were at risk of moderate bias and six had severe bias. The evaluation of the synthesis of evidence showed quality ranging from low to very low. Conclusion AMS, such as audit, feedback, education, implementation of a protocol, and a computer-assisted decision support methodology, appear to be effective in promoting adherence to surgical antibiotic prophylaxis protocols, reducing surgical site infection rate with a positive economic impact. However, more studies, particularly randomized clinical trials, are needed to improve the level of evidence of available information on AMS in order to favor decision-making.
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Affiliation(s)
| | | | - Lucas Borges Pereira
- School of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo, São Paulo, Ribeirão Preto, Brazil
| | | | - Carla Speroni Ceron
- Institute of Exact and Biological Sciences, Federal University of Ouro Preto, Ouro Preto, Minas Gerais, Brazil
| | - Tiago Marques Dos Reis
- Faculty of Pharmaceutical Sciences, Federal University of Alfenas, Alfenas, Minas Gerais, Brazil
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Broom A, Doron A. Resistant bugs, porous borders and ecologies of care in India. Soc Sci Med 2021; 292:114520. [PMID: 34740470 DOI: 10.1016/j.socscimed.2021.114520] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 10/26/2021] [Accepted: 10/27/2021] [Indexed: 11/28/2022]
Abstract
As social science scholarship has routinely illustrated, professional practice is rarely as contained or coherent as it is often imagined to be. The increasing emphasis on the rise of antimicrobial resistance (AMR) has drawn renewed attention to the interconnectedness of clinic, community, environment and planet, and how proposed 'solutions' to major problems such as AMR require a broad, cross-cutting lens. In this study, set in Hyderabad, India, we draw on a series of interviews with hospital-based clinicians completed during 2019 and early 2020, to unpack the multidimensional, ecological acceleration of AMR and the implications for everyday practice. Their accounts make visible how practice operates in relation to industrial economies, community vulnerabilities, and ecologies. This in turn highlights the problem of epistemic bordering, where 'sites' of AMR are targeted but are prone to leakage and transgressions. We propose an ecological approach to conceptualising antimicrobial practices with implications for AMR interventions being rolled out in the sub-continent and beyond.
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Affiliation(s)
- Alex Broom
- Sydney Centre for Healthy Societies, School of Social and Political Sciences, The University of Sydney, New South Wales, Australia.
| | - Assa Doron
- College of Asia & the Pacific, The Australian National University, Australian Capital Territory, Australia.
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Essilini A, Pierre A, Bocquier A, Pulcini C, Wilcke C, Gravoulet J, Demore B, Thilly N. Community pharmacists' views on their current role and future opportunities for antibiotic stewardship: a French qualitative study. JAC Antimicrob Resist 2021; 3:dlab129. [PMID: 34671729 PMCID: PMC8521646 DOI: 10.1093/jacamr/dlab129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 07/26/2021] [Indexed: 11/14/2022] Open
Abstract
Background Different healthcare professionals should contribute to antibiotic stewardship (ABS) activities. Involvement of community pharmacists (CPs) has been little explored worldwide to date. Objectives To explore French CPs' views on ABS and antibiotic resistance, their role and current practices, and future opportunities for ABS. Methods A qualitative study using semi-structured face-to-face individual interviews was performed from May to October 2019 among CPs from north-eastern France. Transcripts of the interviews were analysed using a thematic analysis. Results Twenty-seven interviews were conducted. Most participants had a clear understanding of antibiotic resistance and ABS. They considered themselves as 'guardians of the appropriate use of drugs' but often failed to fulfil this mission because of difficult relationships with physicians. Their current ABS practices are: (i) counselling patients about the antibiotic treatment; and (ii) reporting to the prescriber when they identify contraindications/drug interactions. Concerning their potential increased involvement in ABS, CPs felt they could perform more rapid diagnostic testing for sore throat; they were divided on the possibility for them to change the antibiotic prescription made by a physician and were mainly against the possibility of initiating an antibiotic prescription. The idea of systematically collecting unused antibiotics was perceived well by CPs, while unit dose delivery was not. Conclusions French community pharmacists are willing to become more involved in ABS activities. Collaboration and trust between pharmacists and prescribers should however be improved.
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Affiliation(s)
| | - Amélie Pierre
- Université de Lorraine, APEMAC, F-54000 Nancy, France
| | | | - Céline Pulcini
- Université de Lorraine, APEMAC, F-54000 Nancy, France.,Université de Lorraine, CHRU-Nancy, Service des Maladies Infectieuses et Tropicales, F-54000 Nancy, France
| | - Christophe Wilcke
- Union Régionale des Professionnels de Santé Pharmaciens du Grand Est, 4 rue Piroux, F-54000 Nancy, France
| | - Julien Gravoulet
- Union Régionale des Professionnels de Santé Pharmaciens du Grand Est, 4 rue Piroux, F-54000 Nancy, France.,ANTIBIOEST, CHRU Nancy, Réseau d'Antibiologie, F-54000 Nancy, France
| | - Béatrice Demore
- Université de Lorraine, APEMAC, F-54000 Nancy, France.,ANTIBIOEST, CHRU Nancy, Réseau d'Antibiologie, F-54000 Nancy, France.,Université de Lorraine, CHRU-Nancy, Pôle Pharmacie-Stérilisation, F-54000 Nancy, France
| | - Nathalie Thilly
- Université de Lorraine, APEMAC, F-54000 Nancy, France.,Université de Lorraine, CHRU-Nancy, Département Méthodologie, Promotion, Investigation, F-54000 Nancy, France
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Outpatient antimicrobial stewardship programs in pediatric institutions in 2020: Status, needs, barriers. Infect Control Hosp Epidemiol 2021; 43:1396-1402. [PMID: 34674785 DOI: 10.1017/ice.2021.416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To assess current resources, interventions, and obstacles of pediatric outpatient antimicrobial stewardship programs (ASP). DESIGN Cross-sectional study. SETTING Institutions from the Sharing Antimicrobial Reports for Pediatric Stewardship OutPatient collaborative (SHARPS-OP). PARTICIPANTS Antimicrobial stewardship leaders from the above institutions. METHODS An investigator-developed survey was deployed online in September 2020 to antimicrobial stewardship leaders in SHARPS-OP institutions. The survey was divided into 4 sections: (1) basic information, (2) status of pediatric outpatient ASP in the institutions including financial support, (3) outpatient ASP interventions undertaken by the institutions, and (4) needs and SHARPS-OP collaborative goals. RESULTS Of 56 invited institutions, 45 participated, achieving an 80% response rate. Only 5 sites (11%) had allocated financial support for an outpatient ASP, compared to 42 (95.6%) for their inpatient ASP. The most widely used outpatient ASP interventions included antimicrobial guidance (57.8%), education (46.7%), and quality improvement projects (37.8%). Time was identified as the biggest barrier to expanding outpatient ASPs (91.1%), followed by financial support (53.3%), development of meaningful reports (51.1%), and administrative support (44.4%). Important goals of the collaborative included seeking learning opportunities and developing clear metrics for pediatric outpatient ASP benchmarking. Program needs included securing operational support (35.8%) and strengthening data analysis (31.6%). CONCLUSIONS Very few pediatric institutions with robust inpatient ASPs have devoted time and financial support to advance outpatient efforts. To promote appropriate antibiotic prescribing in the outpatient arena, time and resource funding by administrative leaders are necessary to develop a robust, sustainable stewardship infrastructure.
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Li LX, Szymczak JE, Keller SC. Antibiotic stewardship in direct-to-consumer telemedicine: translating interventions into the virtual realm. J Antimicrob Chemother 2021; 77:13-15. [PMID: 34618026 DOI: 10.1093/jac/dkab371] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Direct-to-consumer (DTC) telemedicine is an increasingly popular modality for delivery of medical care via a virtual platform. As most DTC telemedicine visits focus on infection-related complaints, there is growing concern about the magnitude of antibiotic use associated with this setting. However, there is limited scholarship regarding adapting and implementing antibiotic stewardship principles in this setting as most efforts have been focused on hospitals with more recent work in long-term care facilities and primary care settings. We discuss utilizing the core elements for outpatient antibiotic stewardship as a framework for DTC antibiotic stewardship efforts moving forward.
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Affiliation(s)
- Lucy X Li
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Julia E Szymczak
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Sara C Keller
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Linder JA. Breaking the Ambulatory Antibiotic Prescribing Cycle with All-Antibiotic Stewardship, Patient Stewardship, and Visit Stewardship. Clin Infect Dis 2021; 73:e1680-e1683. [PMID: 32776131 DOI: 10.1093/cid/ciaa1170] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 08/05/2020] [Indexed: 11/14/2022] Open
Affiliation(s)
- Jeffrey A Linder
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Outcomes of clinical decision support for outpatient management of Clostridioides difficile infection. Infect Control Hosp Epidemiol 2021; 43:1345-1348. [PMID: 34583800 DOI: 10.1017/ice.2021.397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To determine the impact of clinical decision support on guideline-concordant Clostridioides difficile infection (CDI) treatment. DESIGN Quasi-experimental study in >50 ambulatory clinics. SETTING Primary, specialty, and urgent-care clinics. PATIENTS Adult patients were eligible for inclusion if they were diagnosed with and treated for a first episode of symptomatic CDI at an ambulatory clinic between November 1, 2019, and November 30, 2020. INTERVENTIONS An outpatient best practice advisory (BPA) was implemented to notify prescribers that "vancomycin or fidaxomicin are preferred over metronidazole for C.difficile infection" when metronidazole was prescribed to a patient with CDI. RESULTS In total, 189 patients were included in the study: 92 before the BPA and 97 after the BPA. Their median age was 59 years; 31% were male; 75% were white; 30% had CDI-related comorbidities; 35% had healthcare exposure; 65% had antibiotic exposure; 44% had gastric acid suppression therapy within 90 days of CDI diagnosis. The BPA was accepted 23 of 26 times and was used to optimize the therapy of 16 patients in 6 months. Guideline-concordant therapy increased after implementation of the BPA (72% vs 91%; P = .001). Vancomycin prescribing increased and metronidazole prescribing decreased after the BPA. There was no difference in clinical response or unplanned encounter within 14 days after treatment initiation. Fewer patients after the BPA had CDI recurrence within 14-56 days of the initial episode (27% vs 7%; P < .001). CONCLUSIONS Clinical decision support increased prescribing of guideline-concordant CDI therapy in the outpatient setting. A targeted BPA is an effective stewardship intervention and may be especially useful in settings with limited antimicrobial stewardship resources.
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Beahm NP, Smyth DJ, Tsuyuki RT. Antimicrobial utilization and stewardship in patients with uncomplicated urinary tract infections managed by pharmacists in the community: A sub-study of the R xOUTMAP trial. JOURNAL OF THE ASSOCIATION OF MEDICAL MICROBIOLOGY AND INFECTIOUS DISEASE CANADA = JOURNAL OFFICIEL DE L'ASSOCIATION POUR LA MICROBIOLOGIE MEDICALE ET L'INFECTIOLOGIE CANADA 2021; 6:205-212. [PMID: 36337761 PMCID: PMC9615465 DOI: 10.3138/jammi-2020-0047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 06/04/2021] [Indexed: 06/16/2023]
Abstract
BACKGROUND Urinary tract infections (UTIs) often lead to suboptimal antibacterial use. Pharmacists are accessible primary care professionals who have an important role to play in antimicrobial stewardship. Our objective was to evaluate the appropriateness of pharmacists' antibacterial prescribing for patients with uncomplicated UTI. METHODS We conducted a prospective registry trial with 39 community pharmacies in New Brunswick, Canada. Adult patients were enrolled if they presented to the pharmacy with either symptoms of UTI with no current antibacterial treatment (pharmacist-initial arm) or an antibacterial prescription for UTI from a physician (physician-initial arm). Pharmacists assessed patients; patients with complicating factors or red flags for systemic illness or pyelonephritis were excluded. Pharmacists prescribed antibacterial therapy or modified antibacterial therapy, provided education only, or referred to a physician, as appropriate. Antibacterial therapy prescribed was compared between study arms. RESULTS Seven hundred fifty patients were enrolled (87% pharmacist-initial arm). The most commonly prescribed agents in the pharmacist-initial arm were nitrofurantoin (88.4%), sulfamethoxazole-trimethoprim (TMP-SMX) (7.8%), and fosfomycin (2.1%); in the physician-initial arm, nitrofurantoin (55.3%), TMP-SMX (25.5%), and fluoroquinolones (10.6%) were prescribed. Therapy was guideline concordant for 95.1% of patients in the pharmacist-initial arm and 35.1% of patients in the physician-initial arm (p < 0.001). For guideline-discordant therapy from physicians, pharmacists prescribed to optimize therapy for 45.9% of patients. CONCLUSION Treatment was highly guideline concordant when pharmacist initiated, with physicians prescribing longer treatment durations and more fluoroquinolones. This represents an important opportunity for antimicrobial stewardship interventions by pharmacists in the community.
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Affiliation(s)
- Nathan P Beahm
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Daniel J Smyth
- Division of Infectious Diseases, Department of Internal Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
- Horizon Health Network, Moncton, New Brunswick, Canada
| | - Ross T Tsuyuki
- Departments of Pharmacology and Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
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Leung V, Langford BJ, Ha R, Schwartz KL. Metrics for evaluating antibiotic use and prescribing in outpatient settings. JAC Antimicrob Resist 2021; 3:dlab098. [PMID: 34286273 PMCID: PMC8287042 DOI: 10.1093/jacamr/dlab098] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Antimicrobial stewardship interventions in outpatient settings are diverse and a variety of outcomes have been used to evaluate these efforts. This narrative review describes, compares and provides specific examples of antibiotic use and other prescribing measures to help antimicrobial stewards better understand, interpret and implement metrics for this setting. A variety of data have been used including those generated from drug sales, prescribing and dispensing activities, however data generated closest to when an individual patient consumes an antibiotic is usually more accurate for estimating antibiotic use. Availability of data is often dependent on context such as information technology infrastructure and the healthcare system under consideration. While there is no ideal antibiotic use or prescribing metric for evaluating antimicrobial stewardship activities in the outpatient setting, the intervention of interest and available data sources are important factors. Common metrics for estimating antimicrobial use include DDD per 1000 inhabitants per day (DID) and days of therapy per 1000 inhabitants/day (DOTID). Other prescribing metrics such as antibiotic prescribing rate (APR), proportion of prescriptions containing an antibiotic, proportion of prolonged antibiotic courses prescribed, estimated appropriate APR and quality indicators are used to assess specific aspects of antimicrobial prescribing behaviour such as initiation, selection, duration and appropriateness. Understanding the context of prescribing practices helps to ensure feasibility and relevance when implementing metrics and targets for improvement in the outpatient setting.
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Affiliation(s)
- Valerie Leung
- Public Health Ontario, ON, Canada
- Toronto East Health Network, Michael Garron Hospital, ON, Canada
| | - Bradley J Langford
- Public Health Ontario, ON, Canada
- Hotel Dieu Shaver Health and Rehabilitation Centre, ON, Canada
| | - Rita Ha
- North York Family Health Team, ON, Canada
| | - Kevin L Schwartz
- Public Health Ontario, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, ON, Canada
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Fleming N, Wilson J, Crawford S, Feeney S. A Quality Improvement Initiative to Improve Antibiotic Stewardship at a Federally Qualified Health Center. J Nurse Pract 2021. [DOI: 10.1016/j.nurpra.2021.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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43
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Lawandi A, Kadri SS. Can financial rewards for stewardship in primary care curb antibiotic resistance? THE LANCET. INFECTIOUS DISEASES 2021; 21:1618-1620. [PMID: 34363775 DOI: 10.1016/s1473-3099(21)00169-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 03/09/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Alexander Lawandi
- Department of Critical Care Medicine, National Institutes of Health Clinical Center, Bethesda, MD 20892, USA
| | - Sameer S Kadri
- Department of Critical Care Medicine, National Institutes of Health Clinical Center, Bethesda, MD 20892, USA.
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Knobloch MJ, Musuuza J, Baubie K, Saban KL, Suda KJ, Safdar N. Nurse practitioners as antibiotic stewards: Examining prescribing patterns and perceptions. Am J Infect Control 2021; 49:1052-1057. [PMID: 33524451 DOI: 10.1016/j.ajic.2021.01.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 01/19/2021] [Accepted: 01/20/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND Advanced practice providers in the outpatient setting play a key role in antibiotic stewardship, yet little is known about how to engage these providers in stewardship activities and what factors influence their antibiotic prescribing practices. METHODS We used mixed methods to obtain data on practices and perceptions related to antibiotic prescribing by nurse practitioners (NP) and Veteran patients. We interviewed NPs working in the outpatient setting at one Veterans Affairs facility and conducted focus groups with Veterans. Emerging themes were mapped to the Systems Engineering Initiative for Patient Safety framework. We examined NP antibiotic prescribing data from 2017 to 2019. RESULTS We interviewed NPs and conducted Veteran focus groups. Nurse practitioners reported satisfaction with resources, including ready access to pharmacists and infectious disease specialists. Building patient trust was reported as essential to prescribing confidence level. Veterans indicated the need to better understand differences between viral and bacterial infections. NP prescribing patterns revealed a decline in antibiotics prescribed for upper respiratory illnesses over a 3-year period. CONCLUSION Outpatient NPs focus on educating the patient while balancing organizational access challenges. Further research is needed to determine how to include both NPs and patients when implementing outpatient antibiotic stewardship strategies. Further research is also needed to understand factors associated with the decline in nurse practitioner antibiotic prescribing observed in this study.
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Grigoryan L, Zoorob R, Germanos G, Sidani M, Horsfield M, Khan F, Zare M, Goebel M, Atmar R, Trautner B. Case-based audit and feedback around a decision aid improved antibiotic choice and duration for uncomplicated cystitis in primary care clinics. Fam Med Community Health 2021; 9:fmch-2020-000834. [PMID: 34244304 PMCID: PMC8273487 DOI: 10.1136/fmch-2020-000834] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES The objective of our study was to evaluate the impact of a multifaceted stewardship intervention on adherence to the evidence-based practice guidelines on treatment of uncomplicated cystitis in primary care. We hypothesised that our intervention would increase guideline adherence in terms of antibiotic choice and duration of treatment. DESIGN A preintervention and postintervention comparison with a contemporaneous control group was performed. During the first two study periods, we obtained baseline data and performed interviews exploring provider prescribing decisions for cystitis at both clinics. During the third period in the intervention clinic only, the intervention included a didactic lecture, a decision algorithm and audit and feedback. We used a difference-in-differences analysis to determine the effects of our intervention on the outcome and guideline adherence to antibiotic choice and duration. SETTING Two family medicine clinics (one intervention and one control) were included. PARTICIPANTS All female patients with uncomplicated cystitis attending the study clinics between 2016 and 2019. RESULTS Our sample included 932 visits representing 812 unique patients with uncomplicated cystitis. The proportion of guideline-adherent antibiotic regimens increased during the intervention period (from 33.2% (95% CI 26.9 to 39.9) to 66.9% (95% CI 58.4 to 74.6) in the intervention site and from 5.3% (95% CI 2.3 to 10.1) to 17.0% (95% CI 9.9 to 26.6) in the control site). The increase in guideline adherence was greater in the intervention site compared with the control site with a difference-in-differences of 22 percentage points, p=0.001. CONCLUSION A multifaceted intervention increased guideline adherence for antibiotic choice and duration in greater magnitude than similar trends at the control site. Future research is needed to facilitate scale-up and sustainability of case-based audit and feedback interventions in primary care.
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Affiliation(s)
- Larissa Grigoryan
- Family and Community Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Roger Zoorob
- Family and Community Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - George Germanos
- Family and Community Medicine, Baylor College of Medicine, Houston, Texas, USA.,Internal Medicine, Desert Regional Medical Center, Palm Springs, California, USA
| | - Mohamad Sidani
- Family and Community Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Matthew Horsfield
- Family and Community Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Fareed Khan
- Family and Community Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Mohammad Zare
- Family and Community Medicine, University of Texas McGovern Medical School, Houston, Texas, USA
| | - Melanie Goebel
- Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Robert Atmar
- Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Barbara Trautner
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Department of Medicine, Baylor College of Medicine, Michael E DeBakey VA Medical Center, Houston, Texas, USA
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Lam TT, Dang DA, Tran HH, Do DV, Le H, Negin J, Jan S, Marks GB, Nguyen TA, Fox GJ, Beardsley J. What are the most effective community-based antimicrobial stewardship interventions in low- and middle-income countries? A narrative review. J Antimicrob Chemother 2021; 76:1117-1129. [PMID: 33491090 DOI: 10.1093/jac/dkaa556] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Antimicrobial resistance (AMR) is a major global issue and antimicrobial stewardship is central to tackling its emergence. The burden of AMR disproportionately impacts low- and middle-income countries (LMICs), where capacity for surveillance and management of resistant pathogens is least developed. Poorly regulated antibiotic consumption in the community is a major driver of AMR, especially in LMICs, yet community-based interventions are neglected in stewardship research, which is often undertaken in high-income settings and/or in hospitals. We reviewed the evidence available to researchers and policymakers testing or implementing community-based antimicrobial stewardship strategies in LMICs. We critically appraise that evidence, deliver recommendations and identify outstanding areas of research need. We find that multifaceted, education-focused interventions are likely most effective in our setting. We also confirm that the quality and quantity of community-based stewardship intervention research is limited, with research on microbiological, clinical and economic sustainability most urgently needed.
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Affiliation(s)
- Thanh Tuan Lam
- The Woolcock Institute of Medical Research, Kim Ma, Ha Noi, Vietnam
| | - Duc Anh Dang
- National Institute of Hygiene and Epidemiology, Hai Ba Trung, Hanoi, Vietnam
| | - Huy Hoang Tran
- National Institute of Hygiene and Epidemiology, Hai Ba Trung, Hanoi, Vietnam
| | - Dung Van Do
- The University of Medicine and Pharmacy, Hong Bang, Q5, Ho Chi Minh City, Vietnam
| | - Hien Le
- The Woolcock Institute of Medical Research, Kim Ma, Ha Noi, Vietnam
| | - Joel Negin
- The Sydney School of Public Health, University of Sydney, NSW 2006, Australia
| | - Stephen Jan
- The George Institute for Global Health, Sydney, NSW 2042, Australia
| | - Guy B Marks
- The University of New South Wales, Sydney, NSW 2052, Australia
| | - Thu Anh Nguyen
- The Woolcock Institute of Medical Research, Kim Ma, Ha Noi, Vietnam.,The Central Clinical School, The Faculty of Medicine and Health, The University of Sydney, NSW 2006, Australia
| | - Greg J Fox
- The Woolcock Institute of Medical Research, Kim Ma, Ha Noi, Vietnam.,The Central Clinical School, The Faculty of Medicine and Health, The University of Sydney, NSW 2006, Australia
| | - Justin Beardsley
- The Marie Bashir Institute, Westmead Institute for Medical Research, The University of Sydney, NSW 2145, Australia.,Oxford University Clinical Research Unit, Vo Van Kiet, Q5, Ho Chi Minh City, Vietnam
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Rolf von den Baumen T, Crosby M, Tadrous M, Schwartz KL, Gomes T. Measuring the impacts of the Using Antibiotics Wisely campaign on Canadian community utilization of oral antibiotics for respiratory tract infections: a time-series analysis from 2015 to 2019. J Antimicrob Chemother 2021; 76:2472-2478. [PMID: 34223899 DOI: 10.1093/jac/dkab205] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 05/24/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND On 1 November 2018, Choosing Wisely Canada launched their Using Antibiotics Wisely primary care campaign, which aimed to reduce unnecessary antibiotic prescriptions for respiratory tract infections (RTIs) through educational tools for patients and providers. OBJECTIVES We explored the impact of this campaign on antibiotic utilization in Canada. METHODS We conducted a population-based study in Canada between January 2015 and December 2019. We used interventional autoregressive integrated moving average models to study the impact of the Using Antibiotics Wisely campaign on the prescribing rate (prescriptions per 1000 population) of RTI-indicated antibiotics. We analysed prescription rates overall and stratified by age group, drug class and province, in each month over the study period. RESULTS There was a 1.5% reduction in the annual prescribing rate of RTI-indicated antibiotics over the study period, which was generally consistent across age groups and provinces. Following the 2018 Using Antibiotics Wisely clinician toolkit release, we observed no significant change in RTI-indicated antibiotic prescribing rates nationally (P = 0.13). This was consistent by age group (children, P = 0.91; adults, P = 0.58; and older adults, P = 0.67) and drug class (narrow-spectrum penicillins, P = 0.88; macrolides, P = 0.85; broad-spectrum penicillins, P = 0.60; cephalosporins, P = 0.45; tetracyclines, P = 0.55; and fluoroquinolones, P = 0.98). In our secondary analysis of prescription rates in provinces that self-identified as prioritizing Using Antibiotics Wisely, we observed no significant change following the launch of the campaign. CONCLUSIONS The introduction of the Using Antibiotics Wisely campaign in Canada has not caused a significant change in short-term antibiotic prescribing patterns. Community antibiotic stewardship campaigns that include components beyond education may be more impactful.
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Affiliation(s)
| | - Michael Crosby
- Leslie Dan Faculty of Pharmacy at the University of Toronto, Toronto, Ontario, Canada
| | - Mina Tadrous
- Leslie Dan Faculty of Pharmacy at the University of Toronto, Toronto, Ontario, Canada.,Women's College Hospital Research Institute, Toronto, Ontario, Canada
| | - Kevin L Schwartz
- Public Health Ontario, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Unity Health Toronto, Toronto, Ontario, Canada
| | - Tara Gomes
- Leslie Dan Faculty of Pharmacy at the University of Toronto, Toronto, Ontario, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation at the University of Toronto, Toronto, Ontario, Canada
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48
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Dutcher L, Degnan K, Adu-Gyamfi AB, Lautenbach E, Cressman L, David MZ, Cluzet V, Szymczak JE, Pegues DA, Bilker W, Tolomeo P, Hamilton KW. Improving Outpatient Antibiotic Prescribing for Respiratory Tract Infections in Primary Care; a Stepped-Wedge Cluster Randomized Trial. Clin Infect Dis 2021; 74:947-956. [PMID: 34212177 DOI: 10.1093/cid/ciab602] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Inappropriate antibiotic prescribing is common in primary care (PC), particularly for respiratory tract diagnoses (RTDs). However, the optimal approach for improving prescribing remains unknown. METHODS We conducted a stepped-wedge study in PC practices within a health system to assess the impact of a provider-targeted intervention on antibiotic prescribing for RTDs. RTDs were grouped into tiers based on appropriateness of antibiotic prescribing: tier 1 (almost always indicated), tier 2 (may be indicated), and tier 3 (rarely indicated). Providers received education on appropriate RTD prescribing followed by monthly peer comparison feedback on antibiotic prescribing for (1) all tiers and (2) tier 3 RTDs. Chi-squared testing was used to compare the proportion of visits with antibiotic prescriptions before and during the intervention. Mixed-effects multivariable logistic regression analysis was performed to assess the association between the intervention and antibiotic prescribing. RESULTS Across 30 PC practices and 185,755 total visits, overall antibiotic prescribing was reduced with the intervention, from 35.2% to 23.0% of visits (p<0.001). In multivariable analysis, the intervention was associated with a reduced odds of antibiotic prescription for tiers 2 (OR 0.57; 95% CI 0.52 - 0.62) and 3 (OR 0.57; 95% CI 0.53 - 0.61), but not for tier 1 (OR 0.98; 95% CI 0.83 - 1.16). CONCLUSION A provider-focused intervention reduced overall antibiotic prescribing for RTDs without affecting prescribing for infections that likely require antibiotics. Future research should examine the sustainability of such interventions, potential unintended adverse effects on patient health or satisfaction, and provider perceptions and acceptability.
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Affiliation(s)
- Lauren Dutcher
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Kathleen Degnan
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Ebbing Lautenbach
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Leigh Cressman
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Michael Z David
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Valerie Cluzet
- Division of Infectious Diseases, Health Quest, Poughkeepsie, NY, USA
| | - Julia E Szymczak
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - David A Pegues
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Warren Bilker
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Pam Tolomeo
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Keith W Hamilton
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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49
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Arieti F, Göpel S, Sibani M, Carrara E, Pezzani MD, Murri R, Mutters NT, Lòpez-Cerero L, Voss A, Cauda R, Tacconelli E. White Paper: Bridging the gap between surveillance data and antimicrobial stewardship in the outpatient sector-practical guidance from the JPIAMR ARCH and COMBACTE-MAGNET EPI-Net networks. J Antimicrob Chemother 2021; 75:ii42-ii51. [PMID: 33280045 PMCID: PMC7719405 DOI: 10.1093/jac/dkaa428] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background The outpatient setting is a key scenario for the implementation of antimicrobial stewardship (AMS) activities, considering that overconsumption of antibiotics occurs mainly outside hospitals. This publication is the result of a joint initiative by the JPIAMR ARCH and COMBACTE-MAGNET EPI-Net networks, which is aimed at formulating a set of target actions for linking surveillance data with AMS activities in the outpatient setting. Methods A scoping review of the literature was carried out in three research areas: AMS leadership and accountability; antimicrobial usage and AMS; antimicrobial resistance and AMS. Consensus on the actions was reached through a RAND-modified Delphi process involving over 40 experts in infectious diseases, clinical microbiology, AMS, veterinary medicine or public health, from 18 low-, middle- and high-income countries. Results Evidence was retrieved from 38 documents, and an initial 25 target actions were proposed, differentiating between essential or desirable targets according to clinical relevance, feasibility and applicability to settings and resources. In the first consultation round, preliminary agreement was reached for all targets. Further to a second review, 6 statements were re-considered and 3 were deleted, leading to a final list of 22 target actions in the form of a practical checklist. Conclusions This White Paper is a pragmatic and flexible tool to guide the development of calibrated surveillance-based AMS interventions specific to the outpatient setting, which is characterized by substantial inter- and intra-country variability in the organization of healthcare structures, maintaining a global perspective and taking into account the feasibility of the target actions in low-resource settings.
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Affiliation(s)
- Fabiana Arieti
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Siri Göpel
- Infectious Diseases, Department of Internal Medicine I, Tübingen University Hospital, Tübingen, Germany.,German Centre for Infection Research (DZIF), Clinical Research Unit for healthcare associated infections, Tübingen, Germany
| | - Marcella Sibani
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Elena Carrara
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Maria Diletta Pezzani
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Rita Murri
- Institute of Infectious Diseases, Fondazione Policlinico Universitario A. Gemelli IRCCS, Universitá Cattolica del Sacro Cuore, Rome, Italy
| | - Nico T Mutters
- Institute of Hygiene and Public Health, Bonn University Hospital, Bonn, Germany
| | - Lorena Lòpez-Cerero
- Microbiology and Infectious Diseases Unit, University Hospital Virgen Macarena, Sevilla, Spain
| | - Andreas Voss
- Department of Clinical Microbiology and Infectious Diseases, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Roberto Cauda
- Institute of Infectious Diseases, Fondazione Policlinico Universitario A. Gemelli IRCCS, Universitá Cattolica del Sacro Cuore, Rome, Italy
| | - Evelina Tacconelli
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy.,Infectious Diseases, Department of Internal Medicine I, Tübingen University Hospital, Tübingen, Germany.,German Centre for Infection Research (DZIF), Clinical Research Unit for healthcare associated infections, Tübingen, Germany
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50
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Delory T, Jeanmougin P, Lariven S, Aubert JP, Peiffer-Smadja N, Boëlle PY, Bouvet E, Lescure FX, Le Bel J. A computerized decision support system (CDSS) for antibiotic prescription in primary care-Antibioclic: implementation, adoption and sustainable use in the era of extended antimicrobial resistance. J Antimicrob Chemother 2021; 75:2353-2362. [PMID: 32357226 DOI: 10.1093/jac/dkaa167] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 03/03/2020] [Accepted: 03/31/2020] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVES To describe the implementation and use of a computerized decision support system (CDSS) for antibiotic prescription in primary care in France (Antibioclic). The CDSS targets 37 infectious diseases and has been freely available on a website since 2011. METHODS Description and implementation of the architecture of a CDSS for antibiotic prescription in general practice. Analysis of the queries made between 2012 and 2018 on the CDSS by GPs. Analysis of two cross-sectional studies of users in 2014 and 2019. RESULTS The number of queries increased from a median of 796/day [IQR, 578-989] in 2012 to 11 125/day [5592-12 505] in 2018. Unique users increased from 414/day [245-494] in 2012 to 5365/day [2891-5769] in 2018. Time taken to make a query was 2 min [1.9-2.1]. Among 3 542 347 queries in 2018, 78% were for adults. Six situations accounted for ≥50% of queries: cystitis; acute otitis media; acute sinusitis; community-acquired pneumonia; sore throat; and pyelonephritis. Queries concerned pathologies for which antibiotic prescription was necessary (64%), was conditional on additional clinical steps (34%) or was not recommended (2%). Most users (81%) were GPs, with median age of 38 years [31-52] and 58% were female. Among the 4016 GPs who responded to the surveys, the vast majority (96%) reported using the CDSS during the consultation, with 24% systematically using Antibioclic to initiate an antibiotic course and 93% having followed the CDSS recommendation for the latest prescription. Most GPs were comfortable using the CDSS in front of a patient. CONCLUSIONS Antibioclic has been adopted and is widely used in primary care in France. Its interoperability could allow its adaptation and implementation in other countries.
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Affiliation(s)
- Tristan Delory
- Antibioclic steering committee, Paris, France.,Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique, IPLESP, F75012 Paris, France.,AP-HP, Bichat hospital, Department of Infectious and Tropical Diseases, Paris, France.,Hôpital Annecy-Genevois (CHANGE), Délégation à la Recherche Clinique et l'Innovation, 1 avenue de l'hôpital, 74370 Epagny-Metz-Tessy, France
| | - Pauline Jeanmougin
- Antibioclic steering committee, Paris, France.,Department of General Practice, Faculty of Medicine, University of Nantes, Nantes, France
| | - Sylvie Lariven
- Antibioclic steering committee, Paris, France.,AP-HP, Bichat hospital, Department of Infectious and Tropical Diseases, Paris, France
| | | | - Nathan Peiffer-Smadja
- AP-HP, Bichat hospital, Department of Infectious and Tropical Diseases, Paris, France.,UMR 1137, INSERM, IAME, Paris, France.,Paris Diderot University Paris 7, Sorbonne Paris Cité, Paris, France
| | - Pierre-Yves Boëlle
- Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique, IPLESP, F75012 Paris, France.,AP-HP, Saint Antoine hospital, Public Health unit, Paris, France
| | - Elisabeth Bouvet
- Antibioclic steering committee, Paris, France.,AP-HP, Bichat hospital, Department of Infectious and Tropical Diseases, Paris, France.,Paris Diderot University Paris 7, Sorbonne Paris Cité, Paris, France.,French National Authority for Health (HAS), Paris, France
| | - François-Xavier Lescure
- Antibioclic steering committee, Paris, France.,AP-HP, Bichat hospital, Department of Infectious and Tropical Diseases, Paris, France.,UMR 1137, INSERM, IAME, Paris, France.,Paris Diderot University Paris 7, Sorbonne Paris Cité, Paris, France
| | - Josselin Le Bel
- Antibioclic steering committee, Paris, France.,UMR 1137, INSERM, IAME, Paris, France.,Department of General Practice, Université Paris Diderot, Université de Paris, Sorbonne Paris Cité, 75018 Paris, France
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