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Alvsåker LKT, Stensen MF, Mjelle AB, Hunskaar S, Rebnord IK. Outcomes of antibiotic treatment for respiratory infections in children an observational study in primary care. Scand J Prim Health Care 2024; 42:237-245. [PMID: 38265029 PMCID: PMC11003315 DOI: 10.1080/02813432.2024.2305929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 01/04/2024] [Indexed: 01/25/2024] Open
Abstract
BACKGROUND Antibiotic resistance is an increasing global threat, accelerated by both misuse and overuse of antibiotics. Most antibiotics to humans are prescribed in primary care, commonly for respiratory symptoms, and there is a need for research on the usage of and outcomes after antibiotic treatment to counteract antibiotic resistance. OBJECTIVE To evaluate symptom duration, treatment length, and adverse events of antibiotic treatment in children. DESIGN AND SETTING Observational study at four out-of-hours services and one paediatric emergency clinic in Norwegian emergency primary care. SUBJECTS 266 children aged 0 to 6 years with fever or respiratory symptoms. MAIN OUTCOME MEASURES Duration of symptoms and absenteeism from kindergarten/school, treatment length, and reported adverse events. RESULTS There were no differences in duration of symptoms, fever or absenteeism when comparing the groups prescribed (30.8%) and not prescribed (69.2%) antibiotics. This lack of difference remained when analysing the subgroup with otitis media.In the group prescribed antibiotics, 84.5% of parents reported giving antibiotics for 5-7 days, and 50.7% reported no difficulties. Adverse events of antibiotics were reported in 42.3% of the cases, the vast majority being gastrointestinal disturbances. CONCLUSION Children with fever or respiratory symptoms experience similar duration of symptoms and absenteeism regardless of antibiotic treatment. A substantial number of parents reported adverse events when the child received antibiotics. Several parents experienced additional difficulties with the treatment, some ending treatment within day 4. TRIAL REGISTRATION NUMBER NCT02496559; Results.
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Affiliation(s)
| | | | - Anders Batman Mjelle
- Department of Anaesthesiology and Intensive Care, Stavanger University Hospital, Stavanger, Norway
| | - Steinar Hunskaar
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Bergen, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Ingrid Keilegavlen Rebnord
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Bergen, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
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2
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Mozes I, Baron-Epel O, Heymann A. Impact of Remote Medical Devices on Utilization of Medical Services in Pediatric Patients with Upper Respiratory Infections: A Retrospective Study. Health Informatics J 2024; 30:14604582241233996. [PMID: 38587170 DOI: 10.1177/14604582241233996] [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] [Indexed: 04/09/2024]
Abstract
Background: Remote mobile examination devices in telemedicine are a new technology in healthcare. Objective: To assess the utilization of visits using remote medical devices. Methods: A retrospective analysis of follow-up visits, referrals, laboratory testing and antibiotic prescriptions of 470,845 children's video visits with and without remote medical examination device and in-clinic visits. Results: Rates of follow-up visits, referrals and laboratory tests were higher in video visits compared to visit with medical device (OR of 1.27, 1.08, 1.93 respectfully). For in-clinic visits, rates of follow-up were lower but higher for referrals to subspecialists and laboratory test referrals when compared to telemedicine. Antibiotic prescriptions were provided at a lower rate in video visits compared to visits with a medical device (OR = 0.48) and in-clinic visits. Conclusions: Incorporating a remote medical device may reduce follow up visits, referrals and laboratory tests compared to a video visit without a device. The prevalence of antibiotic prescriptions did not escalate in telemedicine consultations.
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Affiliation(s)
- Inbal Mozes
- School of Public Health, Haifa University, Haifa, Israel
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Krueger C, Alqurashi W, Barrowman N, Litwinska M, Le Saux N. The long and the short of pediatric emergency department antibiotic prescribing: A retrospective observational study. Am J Emerg Med 2024; 75:131-136. [PMID: 37950980 DOI: 10.1016/j.ajem.2023.10.052] [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: 05/29/2023] [Revised: 10/27/2023] [Accepted: 10/28/2023] [Indexed: 11/13/2023] Open
Abstract
BACKGROUND Most antibiotics prescribed to children are provided in the outpatient and emergency department (ED) settings, yet these prescribers are seldom engaged by antibiotic stewardship programs. We reviewed ED antibiotic prescriptions for three common infections to describe current prescribing practices. METHODS Prescription data between 2018 and 2021 were extracted from the electronic records of children discharged from the Children's Hospital of Eastern Ontario ED with urinary tract infection (UTI), community acquired pneumonia (CAP), and acute otitis media ≥2 years of age (AOM). Antibiotic choice, duration, as well as the provider's time in practice and training background were collected. Antibiotic durations were compared with Canadian guideline recommendations to assess concordance. Provider-level prescribing practices were analyzed using k-means cluster analysis. RESULTS 10,609 prescriptions were included: 2868 for UTI, 2958 for CAP, and 4783 for AOM. Guideline-concordant durations prescribed was generally high (UTI 84.9%, CAP 94.0%, AOM 52.8%), a large proportion of antibiotic-days prescribed were in excess of the minimally recommended duration for each infection (UTI 16.8%, 19.3%, AOM 25.5%). Cluster analysis yielded two clusters of prescribers, with those in one cluster more commonly prescribing durations at the lower end of recommended interval, and the others more commonly prescribing longer durations for all three infections reviewed. No statistically significant differences were found between clusters by career stage or training background. CONCLUSIONS While guideline-concordant antibiotic prescribing was generally high, auditing antibiotic prescriptions identified shifting prescribing towards the minimally recommended duration as a potential opportunity to reduce antibiotic use among children for these infections.
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Affiliation(s)
- Carsten Krueger
- Division of Infectious Diseases, Immunology & Allergy, Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada.
| | - Waleed Alqurashi
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Nicholas Barrowman
- Children's Hospital of Eastern Ontario Research Institute, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Maria Litwinska
- Business Intelligence Team, Information Services, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Nicole Le Saux
- Division of Infectious Diseases, Immunology & Allergy, Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
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Qureshi N, Kroger J, Zangwill KM, Joshi NS, Payton K, Mendel P. Changes in perceptions of antibiotic stewardship among neonatal intensive care unit providers over the course of a learning collaborative: a prospective, multisite, mixed-methods evaluation. J Perinatol 2024; 44:62-70. [PMID: 38001155 PMCID: PMC10783543 DOI: 10.1038/s41372-023-01823-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 10/18/2023] [Accepted: 11/03/2023] [Indexed: 11/26/2023]
Abstract
OBJECTIVE To assess clinician perceptions towards the value and implementation of antibiotic stewardship (AS) in neonatal intensive care units (NICU). STUDY DESIGN We performed a mixed-methods study of AS perceptions (prescribing appropriateness, importance, activity, capacity) using surveys and interviews in 30 California NICUs before and after a multicenter collaborative (Optimizing Antibiotic Use in California NICUs [OASCN]). RESULTS Pre-OASCN, 24% of respondents felt there was "a lot of" or "some" inappropriate prescribing, often driven by fear of a bad outcome or reluctance to change existing practice. Clinicians reported statistically significant increases in AS importance (71 v 79%), perceived AS activity (67 v 87%), and more openness to change after OASCN (59 v 70%). We identified other concerns that lessen AS effort. CONCLUSION OASCN increased perceived AS activity and openness to change in AS practices among NICU prescribers. Greater attention to subjective concerns should augment AS improvement.
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Affiliation(s)
- Nabeel Qureshi
- RAND Corporation, Santa Monica, CA, USA.
- Pardee RAND Graduate School, Santa Monica, CA, USA.
| | - Jack Kroger
- RAND Corporation, Santa Monica, CA, USA
- Pardee RAND Graduate School, Santa Monica, CA, USA
| | - Kenneth M Zangwill
- Division of Pediatric Infectious Diseases and The Lundquist Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Neha S Joshi
- Stanford University, Division of Pediatric Hospital Medicine, Palo Alto, CA, USA
| | - Kurlen Payton
- Cedars-Sinai Medical Center, Department of Pediatrics, Division of Neonatology, Los Angeles, CA, USA
- California Perinatal Quality Care Collaborative, Stanford, CA, USA
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5
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Szymczak JE, Hayes AA, Labellarte P, Zighelboim J, Toor A, Becker AB, Gerber JS, Kuppermann N, Florin TA. Parent and Clinician Views on Not Using Antibiotics for Mild Community-Acquired Pneumonia. Pediatrics 2024; 153:e2023063782. [PMID: 38234215 DOI: 10.1542/peds.2023-063782] [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] [Accepted: 10/31/2023] [Indexed: 01/19/2024] Open
Abstract
OBJECTIVES Preschool-aged children with mild community-acquired pneumonia (CAP) routinely receive antibiotics even though most infections are viral. We sought to identify barriers to the implementation of a "no antibiotic" strategy for mild CAP in young children. METHODS Qualitative study using semistructured interviews conducted in a large pediatric hospital in the United States from January 2021 to July 2021. Parents of young children diagnosed with mild CAP in the previous 3 years and clinicians practicing in outpatient settings (pediatric emergency department, community emergency department, general pediatrics offices) were included. RESULTS Interviews were conducted with 38 respondents (18 parents, 20 clinicians). No parent heard of the no antibiotic strategy, and parents varied in their support for the approach. Degree of support related to their desire to avoid unnecessary medications, trust in clinicians, the emotional difficulty of caring for a sick child, desire for relief of suffering, willingness to accept the risk of unnecessary antibiotics, and judgment about the child's illness severity. Eleven (55%) clinicians were familiar with guidelines specifying a no antibiotic strategy. They identified challenges in not using antibiotics, including diagnostic uncertainty, consequences of undertreatment, parental expectations, follow-up concerns, and acceptance of the risks of unnecessary antibiotic treatment of many children if it means avoiding adverse outcomes for some children. CONCLUSIONS Although both parents and clinicians expressed broad support for the judicious use of antibiotics, pneumonia presents stewardship challenges. Interventions will need to consider the emotional, social, and logistical aspects of managing pneumonia, in addition to developing techniques to improve diagnosis.
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Affiliation(s)
- Julia E Szymczak
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Ashley A Hayes
- Smith Child Health Catalyst, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Patricia Labellarte
- Smith Child Health Catalyst, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Julian Zighelboim
- Smith Child Health Catalyst, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Amandeep Toor
- Smith Child Health Catalyst, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Adam B Becker
- Smith Child Health Catalyst, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jeffrey S Gerber
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nathan Kuppermann
- Departments of Emergency Medicine and Pediatrics, University of California, Davis, School of Medicine, Sacramento, California
| | - Todd A Florin
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Abstract
Most antibiotics are prescribed in ambulatory setting and at least 30% to 50% of these prescriptions are unnecessary. The use of antibiotics when not needed promotes the development of antibiotic resistant organisms and harms patients by placing them at risk for adverse drug events and Clostridioides difficile infections. National guidelines recommend that health systems implement antibiotic stewardship programs in ambulatory settings. However, uptake of stewardship in ambulatory setting has remained low. This review discusses the current state of ambulatory stewardship in the United States, best practices for the successful implementation of effective ambulatory stewardship programs, and future directions to improve antibiotic use in ambulatory settings.
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Affiliation(s)
- Holly M Frost
- Center for Health Systems Research, Denver Health and Hospital Authority, Denver, CO, USA; Department of Pediatrics, Denver Health and Hospital Authority, Denver, CO, USA; Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Adam L Hersh
- Division of Infectious Disease, Department of Pediatrics, 295 Chipeta Way, Salt Lake City, UT 8413, USA
| | - David Y Hyun
- Antimicrobial Resistance Project, The Pew Charitable Trusts, 901 East Street NW, Washington, DC 20004-2008, USA
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7
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Patient expectations do matter - Experimental evidence on antibiotic prescribing decisions among hospital-based physicians. Health Policy 2023; 128:11-17. [PMID: 36450627 DOI: 10.1016/j.healthpol.2022.11.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 10/28/2022] [Accepted: 11/17/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND The global public health crisis of antibiotic resistance is being driven in part by over prescription of antibiotics. We aimed to assess the relative weight of patient expectations, clinical uncertainty, and past behaviour on hospital-based physicians' antibiotic prescribing decisions. METHODS A discrete choice experiment was administered among hospital-based physicians in Tuscany, Italy. Respondents were asked to choose in which of two clinical scenarios they would be more likely to prescribe antibiotics, with the two cases differing in levels of clinical uncertainty, patient expectations, and the physician's past behaviour. We fitted a conditional logistic regression. RESULTS Respondents included 1,436 hospital-based physicians. Results show that the odds of prescribing antibiotics decrease when a patient requests it (OR=0.80, 95%CI [0.72,0.89]) and increase when the physician has prescribed antibiotics to a patient under similar circumstances previously (OR=1.15, 95%CI [1.03,1.27]). We found no significant effect of clinical uncertainty on the odds of prescribing antibiotics (OR=0.96, 95%CI [0.87, 1.07]). CONCLUSIONS We show that patient expectation has a significant negative association with antibiotic prescribing among hospital-based physicians. Our findings speak to the importance of cultural context in shaping the physician's disposition when confronted with patient expectations. We suggest shared decision-making to improve prudent prescribing without compromising on patient satisfaction.
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Alejandro AL, Leo WWC, Bruce M, Gimutao K. Does antibiotic awareness campaigns exposure decrease intention to demand antibiotic treatment? Testing a structural model among parents in Western Australia. PLoS One 2023; 18:e0285396. [PMID: 37200317 DOI: 10.1371/journal.pone.0285396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 04/22/2023] [Indexed: 05/20/2023] Open
Abstract
Antimicrobial resistance (AMR) is one of the key public health concerns the world is facing today. The effect of antibiotic awareness campaigns (AACs) on consumer behaviour has been documented in the literature with mixed results. Understanding the mechanism for how AACs affect target populations is vital in designing effective and tailored campaigns. Using structural equation modelling our study examined the relationships among people's exposure to antibiotic awareness campaigns, knowledge of AMR prevention, AMR risk perception, and intention to seek antibiotic treatment. This study also tested the moderating effect of anxiety and societal responsibility on preventing AMR, and on their intention to demand antibiotic treatment mediated by knowledge of AMR prevention and risk-perception. Primary data was generated using an online survey of 250 Western Australian parents. We tested our hypotheses using reliability and validity tests and structural equation modelling. Our results show that exposure to AACs alone may not be enough to change parental intention to demand antibiotic prescription for their children. Parental risk perception of AMR and parental anxiety affect intention to demand antibiotics, and the view that AMR is a social responsibility has a moderating effect on intention to demand antibiotics. These factors could be considered and combine messaging strategies in designing future antibiotic awareness campaigns.
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Affiliation(s)
- Aaron Lapuz Alejandro
- Centre for Biosecurity and One Health, Harry Butler Institute, Murdoch University, Murdoch, Australia
- School of Nursing and Midwifery, Edith Cowan University, Joondalup, Australia
- Fiona Stanley Hospital, Murdoch, Australia
| | | | - Mieghan Bruce
- Centre for Biosecurity and One Health, Harry Butler Institute, Murdoch University, Murdoch, Australia
- School of Veterinary Medicine, Murdoch University, Murdoch, Australia
| | - Kaymart Gimutao
- Developmental Communication, University of the Philippines, Los Baños, Philippines
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9
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McIsaac WJ, Kukan S. Assessing the Validity of Electronic Medical Records for Identifying High Antibiotic Prescribers in Primary Care. J Prim Care Community Health 2023; 14:21501319231210616. [PMID: 37978835 PMCID: PMC10657523 DOI: 10.1177/21501319231210616] [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: 08/17/2023] [Revised: 10/06/2023] [Accepted: 10/11/2023] [Indexed: 11/19/2023] Open
Abstract
OBJECTIVES Electronic medical record (EMR) prescription data may identify high antibiotic prescribers in primary care. However, practitioners doubt that population differences between providers and delayed antibiotic prescriptions are adequately accounted for in EMR-derived prescription rates. This study assessed the validity of using EMR prescription data to produce antibiotic prescription rates, accounting for these factors. METHODS The study was a secondary analysis of antimicrobial prescriptions collected from 4 primary care clinics from 2015 to 2017. For adults with selected respiratory and urinary infections, EMR diagnostic codes, prescription data, clinical diagnoses and demographics were abstracted. Overall and delayed prescription rates were produced for EMR diagnostic codes, clinical diagnoses, by clinic, and types of infection. Direct standardization was used to adjust for case mix differences by clinic. High antibiotic prescribers, above the 75th percentile for prescriptions, were compared with low antibiotic prescribers. RESULTS Of 3108 EMR visits, there were 2577 (85.4%) eligible visits with a clinical diagnosis and prescription information. Overall antibiotic prescription rates were similar utilizing EMR records (31.6%) or clinical diagnoses (32.6%, P = .40). When delayed prescriptions were removed, prescribing rates were lower (22.4%, P < .01). EMR data overestimated prescribing rates for conditions where antibiotics are usually not indicated (17.7% EMR vs 7.6% clinical diagnoses, P < .001). High antibiotic prescribers saw more cases where antibiotics are usually indicated (23.4%) compared to low prescribers (16.8%; P = .001). CONCLUSIONS Electronic medical record prescribing rates are similar to those using clinical diagnoses overall, but overestimate prescribing by clinicians for conditions usually not needing antibiotics. EMR prescription rates do not account for delayed antibiotic prescriptions or differences in infection case-mix.
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Affiliation(s)
- Warren J. McIsaac
- Sinai Health, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
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10
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Suttels V, Van Singer M, Clack LC, Plüss-Suard C, Niquille A, Mueller Y, Boillat Blanco N. Factors Influencing the Implementation of Antimicrobial Stewardship in Primary Care: A Narrative Review. Antibiotics (Basel) 2022; 12:antibiotics12010030. [PMID: 36671230 PMCID: PMC9854946 DOI: 10.3390/antibiotics12010030] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 12/20/2022] [Accepted: 12/22/2022] [Indexed: 12/29/2022] Open
Abstract
Antimicrobial resistance (AMR) is directly driven by inappropriate use of antibiotics. Although the majority of antibiotics (an estimated 80%) are consumed in primary care settings, antimicrobial stewardship (AMS) activities in primary care remain underdeveloped and factors influencing their implementation are poorly understood. This can result in promising stewardship activities having little-to-no real-world impact. With this narrative review, we aim to identify and summarize peer-reviewed literature reporting on (1) the nature and impact of AMS interventions in primary care and (2) the individual and contextual factors influencing their implementation. Reported activities included AMS at different contextual levels (individual, collective and policy). AMS activities being often combined, it is difficult to evaluate them as stand-alone interventions. While some important individual and contextual factors were reported (difficulty to reach physicians leading to a low uptake of interventions, tight workflow of physicians requiring implementation of flexible and brief interventions and AMS as a unique opportunity to strengthen physician-patients relationship), this review identified a paucity of information in the literature about the factors that support or hinder implementation of AMS in primary care settings. In conclusion, identifying multilevel barriers and facilitators for AMS uptake is an essential step to explore before implementing primary care AMS interventions.
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Affiliation(s)
- Véronique Suttels
- Infectious Diseases Service, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
- Correspondence:
| | - Mathias Van Singer
- Infectious Diseases Service, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - Lauren Catherine Clack
- Institute for Implementation Science in Health Care, Medical Faculty, University of Zurich, 8006 Zürich, Switzerland
| | - Catherine Plüss-Suard
- Swiss Centre for Antibiotic Resistance, Institute for Infectious Diseases, University of Bern, 3001 Bern, Switzerland
| | - Anne Niquille
- Center for Primary Care and Public Health (Unisanté), Pharmacy University of Lausanne, 1011 Lausanne, Switzerland
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Lausanne, 1011 Lausanne, Switzerland
| | - Yolanda Mueller
- Center for Primary Care and Public Health (Unisanté), Department of Family Medicine, 1011 Lausanne, Switzerland
| | - Noémie Boillat Blanco
- Infectious Diseases Service, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
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11
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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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12
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Goggin K, Hurley EA, Lee BR, Bradley-Ewing A, Bickford C, Pina K, Donis de Miranda E, Yu D, Weltmer K, Linnemayr S, Butler CC, Newland JG, Myers AL. Let's Talk About Antibiotics: a randomised trial of two interventions to reduce antibiotic misuse. BMJ Open 2022; 12:e049258. [PMID: 36410835 PMCID: PMC9680140 DOI: 10.1136/bmjopen-2021-049258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Children with acute respiratory tract infections (ARTIs) receive ≈11.4 million unnecessary antibiotic prescriptions annually. A noted contributor is inadequate parent-clinician communication, however, efforts to reduce overprescribing have only indirectly targeted communication or been impractical. OBJECTIVES Compare two feasible (higher vs lower intensity) interventions for enhancing parent-clinician communication on the rate of inappropriate antibiotic prescribing. DESIGN Multisite, parallel group, cluster randomised comparative effectiveness trial. Data collected between March 2017 and March 2019. SETTING Academic and private practice outpatient clinics. PARTICIPANTS Clinicians (n=41, 85% of eligible approached) and 1599 parent-child dyads (ages 1-5 years with ARTI symptoms, 71% of eligible approached). INTERVENTIONS All clinicians received 20 min ARTI diagnosis and treatment education. Higher intensity clinicians received an additional 50 min communication skills training. All parents viewed a 90 second antibiotic education video. MAIN OUTCOMES AND MEASURES Inappropriate antibiotic treatment was assessed via blinded medical record review by study clinicians and a priori defined as prescriptions for the wrong diagnosis or use of the wrong agent. Secondary outcomes were revisits, adverse drug reactions (both assessed 2 weeks after the visit) and parent ratings of provider communication, shared decision-making and visit satisfaction (assessed at end of the visit on Likert-type scales). RESULTS Most clinicians completed the study (n=38, 93%), were doctors (n=25, 66%), female (n=30, 78%) and averaged 8 years in practice. All parent-child dyad provided data for the main outcome (n=855 (54%) male, n=1043 (53%) <2 years). Inappropriate antibiotic prescribing was similar among patients who consulted with a higher intensity (54/696, 7.8%) versus a lower intensity (85/904, 9.4%) clinician. A generalised linear mixed effect regression model (adjusted for the two-stage nested design, clinician type, clinic setting and clinician experience) revealed that the odds of receiving inappropriate antibiotic treatment did not significantly vary by group (AOR 0.99, 95% CI: 0.52 to 1.89, p=0.98). Secondary outcomes of revisits and adverse reactions did not vary between arms, and parent ratings of satisfaction with quality of parent-provider communication (5/5), shared decision making (9/10) and visit satisfaction (5/5) were similarly high in both arms. CONCLUSIONS AND RELEVANCE Rate of inappropriate prescribing was low in both arms. Clinician education coupled with parent education may be sufficient to yield low inappropriate antibiotic prescribing rates. The absence of a significant difference between groups indicates that communication principles previously thought to drive inappropriate prescribing may need to be re-examined or may not have as much of an impact in practices where prescribing has improved in recent years. TRIAL REGISTRATION NUMBER NCT03037112.
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Affiliation(s)
- Kathy Goggin
- Health Services and Outcomes Research, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, USA
- School of Medicine, University of Missouri - Kansas City, Kansas City, MO, USA
- School of Pharmacy, University of Missouri - Kansas City, Kansas City, MO, USA
| | - Emily A Hurley
- Health Services and Outcomes Research, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, USA
- School of Medicine, University of Missouri - Kansas City, Kansas City, MO, USA
| | - Brian R Lee
- Health Services and Outcomes Research, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, USA
- School of Medicine, University of Missouri - Kansas City, Kansas City, MO, USA
| | - Andrea Bradley-Ewing
- Health Services and Outcomes Research, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, USA
- School of Medicine, University of Missouri - Kansas City, Kansas City, MO, USA
| | - Carey Bickford
- Health Services and Outcomes Research, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, USA
| | - Kimberly Pina
- Health Services and Outcomes Research, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, USA
| | - Evelyn Donis de Miranda
- Health Services and Outcomes Research, Children's Mercy Hospitals and Clinics, Kansas City, Missouri, USA
| | - David Yu
- Sunflower Medical Group, Kansas City, Kansas, USA
| | - Kirsten Weltmer
- School of Medicine, University of Missouri - Kansas City, Kansas City, MO, USA
- General Academic Pediatrics, Children's Mercy Hospitals and Clinics, Kansas City, MO, USA
| | | | - Christopher C Butler
- Nuffield Department of Primary Health Care Sciences, University of Oxford, Oxford, UK
| | - Jason G Newland
- Division of Infectious Diseases, Department of Pediatrics, Washington University in St. Louis, St. Louis, MO, USA
| | - Angela L Myers
- Pediatric Infectious Diseases, Children's Mercy Hospitals and Clinics, Kansas City, MO, USA
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13
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Whitelock-Wainwright E, Koh JW, Whitelock-Wainwright A, Talic S, Rankin D, Gašević D. An exploration into physician and surgeon data sensemaking: a qualitative systematic review using thematic synthesis. BMC Med Inform Decis Mak 2022; 22:256. [PMID: 36171583 PMCID: PMC9520820 DOI: 10.1186/s12911-022-01997-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 09/12/2022] [Indexed: 11/10/2022] Open
Abstract
Providing electronic health data to medical practitioners to reflect on their performance can lead to improved clinical performance and quality of care. Understanding the sensemaking process that is enacted when practitioners are presented with such data is vital to ensure an improvement in performance. Thus, the primary objective of this research was to explore physician and surgeon sensemaking when presented with electronic health data associated with their clinical performance. A systematic literature review was conducted to analyse qualitative research that explored physicians and surgeons experiences with electronic health data associated with their clinical performance published between January 2010 and March 2022. Included articles were assessed for quality, thematically synthesised, and discussed from the perspective of sensemaking. The initial search strategy for this review returned 8,829 articles that were screened at title and abstract level. Subsequent screening found 11 articles that met the eligibility criteria and were retained for analyses. Two articles met all of the standards within the chosen quality assessment (Standards for Reporting Qualitative Research, SRQR). Thematic synthesis generated five overarching themes: data communication, performance reflection, infrastructure, data quality, and risks. The confidence of such findings is reported using CERQual (Confidence in the Evidence from Reviews of Qualitative research). The way the data is communicated can impact sensemaking which has implications on what is learned and has impact on future performance. Many factors including data accuracy, validity, infrastructure, culture can also impact sensemaking and have ramifications on future practice. Providing data in order to support performance reflection is not without risks, both behavioural and affective. The latter of which can impact the practitioner's ability to effectively make sense of the data. An important consideration when data is presented with the intent to improve performance.Registration This systematic review was registered with Prospero, registration number: CRD42020197392.
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Affiliation(s)
- Emma Whitelock-Wainwright
- Faculty of Information Technology, Centre for Learning Analytics (CoLAM), Monash University, Melbourne, Australia
- Practice Analytics, DHCRC, Sydney, Australia
| | - Jia Wei Koh
- Faculty of Information Technology, Centre for Learning Analytics (CoLAM), Monash University, Melbourne, Australia
- Practice Analytics, DHCRC, Sydney, Australia
| | | | - Stella Talic
- School of Public Health and Preventative Medicine, Monash University, Melbourne, Australia
- Practice Analytics, DHCRC, Sydney, Australia
| | - David Rankin
- Clinical Governance and Informatics, Cabrini Health, Melbourne, Australia
- Practice Analytics, DHCRC, Sydney, Australia
| | - Dragan Gašević
- Faculty of Information Technology, Centre for Learning Analytics (CoLAM), Monash University, Melbourne, Australia
- Practice Analytics, DHCRC, Sydney, Australia
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Keller SC, Cosgrove SE, Miller MA, Tamma P. A framework for implementing antibiotic stewardship in ambulatory care: Lessons learned from the Agency for Healthcare Research and Quality Safety Program for Improving Antibiotic Use. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2022; 2:e109. [PMID: 36483406 PMCID: PMC9726561 DOI: 10.1017/ash.2022.258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 05/31/2022] [Accepted: 06/01/2022] [Indexed: 06/17/2023]
Abstract
Antibiotic overuse is common in ambulatory care settings, underscoring the importance of outpatient antibiotic stewardship to ensure safe and effective antibiotic prescription. In response to this need, the Agency for Healthcare Research and Quality (AHRQ) developed the AHRQ Safety Program for Improving Antibiotic Use in Ambulatory Care. The Safety Program successfully assisted 389 outpatient practices across the United States to establish ambulatory antibiotic stewardship. Herein, we have used lessons learned from the AHRQ Safety Program to describe a step-by-step framework to assist practices with establishing antibiotic stewardship in the outpatient setting. Steps include obtaining support from practice leadership; establishing an antibiotic stewardship team; garnering support from practice members; determining how to access antibiotic prescribing data; building communication skills around antibiotic use in the practice; implementing educational content around an infectious syndrome; monitoring antibiotic prescription data; and implementing a sustainability plan.
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Affiliation(s)
- Sara C. Keller
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sara E. Cosgrove
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Melissa A. Miller
- Center for Quality Improvement and Patient Safety, Agency for Healthcare Research and Quality, Rockville, Maryland
| | - Pranita Tamma
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
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15
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Spencer HJJ, Katz S, Staub M, Audet CM, Banerjee R. A qualitative assessment of nonclinical drivers of pediatric outpatient antibiotic prescribing: The importance of continuity. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2022; 2:e107. [PMID: 36483400 PMCID: PMC9726583 DOI: 10.1017/ash.2022.224] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 04/12/2022] [Accepted: 04/13/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND AND OBJECTIVES Antibiotic overuse is common in outpatient pediatrics and varies across clinical setting and clinician type. We sought to identify social, behavioral, and environmental drivers of outpatient antibiotic prescribing for pediatric patients. METHODS We conducted semistructured interviews with physicians and advanced practice providers (APPs) across diverse outpatient settings including pediatric primary, urgent, and retail care. We used the grounded theory constant comparative method and a thematic approach to analysis. We developed a conceptual model, building on domains of continuity to map common themes and their relationships within the healthcare system. RESULTS We interviewed 55 physicians and APPs. Clinicians across all settings prioritized provision of guideline-concordant care but implemented these guidelines with varying degrees of success. The provision of guideline-concordant care was influenced by the patient-clinician relationship and patient or parent expectations (relational continuity); the clinician's access to patient clinical history (informational continuity); and the consistency of care delivered (management continuity). No difference in described themes was determined by setting or clinician type; however, clinicians in primary care described having more reliable relational and informational continuity. CONCLUSIONS Clinicians described the absence of long-term relationships (relational continuity) and lack of availability of prior clinical history (informational continuity) as factors that may influence outpatient antibiotic prescribing. Guideline-concordant outpatient antibiotic prescribing was facilitated by consistent practice across settings (management continuity) and the presence of relational and informational continuity, which are common only in primary care. Management continuity may be more modifiable than informational and relational continuity and thus a focus for outpatient stewardship programs.
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Affiliation(s)
- Hillary J. J. Spencer
- Division of Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sophie Katz
- Division of Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Milner Staub
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Carolyn M. Audet
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ritu Banerjee
- Division of Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
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16
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Communicating Commitment to Antibiotic Stewardship: an Effective Strategy for Responding to Online Patient Reviews. Int J Behav Med 2022; 30:416-423. [PMID: 35618989 DOI: 10.1007/s12529-022-10102-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Public health officials have worked to address the growing threat of antibiotic resistance. To slow the emergence of antimicrobial-resistant bacteria, it is important to improve patients' understanding of antibiotics and adjust their expectations of them. This study explores strategic antibiotic resistance communication between patients and health care providers in an online review platform. METHODS Based on two experimental studies, we demonstrate the effectiveness of the provider's commitment messaging when dealing with patients' complaints about not receiving requested antibiotics during their visit. RESULTS The findings from study 1 show that communicating the commitment to antibiotic stewardship makes participants have more favorable feelings toward the provider. Commitment messaging also makes readers perceive the provider as more credible, and they are more willing to visit the clinic in the future. Study 2 findings demonstrate a robustness of commitment messaging in increasing readers' willingness to visit the clinic, while the provider's response exhibits the limited impact of correcting patients' common misunderstandings of antibiotics and adjusting their expectations of antibiotics. CONCLUSIONS Our findings illustrate some clear benefits of engaging with negative online patient reviews to minimize potential reputational damage and reestablish the credibility of care providers.
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17
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Turner MM, Choung H, Bui QHHM, Beck P, Ashraf H. Reversing the Antibiotic Resistance “Yelp Effect” Through the Use of Emotionally Framed Responses to Negative Reviews of Providers: Questionnaire Study. JMIR Form Res 2022; 6:e26122. [PMID: 35315787 PMCID: PMC8984826 DOI: 10.2196/26122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 04/05/2021] [Accepted: 01/05/2022] [Indexed: 11/13/2022] Open
Abstract
Background The overuse of antibiotics has rapidly made antimicrobial resistance a global public health challenge. There is an emerging trend where providers who perceive that their patients expect antibiotics are more likely to prescribe antibiotics unprompted or upon request. Particularly, health care providers have expressed concern that dissatisfied patients will provide disparaging online reviews, therefore threatening the reputation of the practice. To better deal with the negative reviews and inform patients, some health care staff directly respond to patients’ online feedback. Engaging with patients’ online reviews gives providers an opportunity to prevent reputational damage and improve patients’ understanding of the antibiotic resistance problem. Objective We aim to test the effectiveness of different response strategies to the negative patient online reviews on the readers’ perceptions of the health care provider and their perceptions related to antibiotics resistance. Methods Two experiments were conducted to examine the impact of message tactics (apologizing, inducing fear or guilt) that can be employed by health care providers when responding to patients’ negative online feedback related to not receiving an antibiotic. Results Overall, our results demonstrated positive impacts of responding to patients’ online reviews. In study 1, we found apologetic messaging and use of emotional appeals in the response were effective in making readers feel more favorable toward the message. Readers also expressed a greater credibility perception toward the provider and willingness to visit the clinic when emotional appeals were used. Findings from study 2 largely supported the effectiveness of a fear-based response in improving the readers’ credibility perceptions and willingness to visit the clinic. The fear-inducing information was particularly effective among parent readers. Conclusions This paper demonstrated that a strategic response to online patient complaints could prevent reputational damage and minimize the potential negative impacts of the review. The results also glean insight into the step toward developing a novel intervention—crafting a persuasive response to patients’ negative feedback that can help improve the understanding of antibiotic resistance problems.
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Affiliation(s)
- Monique Mitchell Turner
- College of Communication Arts and Sciences, Michigan State University, East Lansing, MI, United States
| | - Hyesun Choung
- College of Communication Arts and Sciences, Michigan State University, East Lansing, MI, United States
| | - Quoc-Ha Hannah Mai Bui
- Milken Institute School of Public Health, George Washington University, Washington, DC, United States
| | - Paige Beck
- Milken Institute School of Public Health, George Washington University, Washington, DC, United States
| | - Hera Ashraf
- Milken Institute School of Public Health, George Washington University, Washington, DC, United States
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18
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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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19
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Setiawan E, Cotta MO, Abdul-Aziz MH, Sosilya H, Widjanarko D, Wardhani DK, Roberts JA. Indonesian healthcare providers' perceptions and attitude on antimicrobial resistance, prescription and stewardship programs. Future Microbiol 2022; 17:363-375. [PMID: 35212232 DOI: 10.2217/fmb-2021-0193] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background: A successful antimicrobial stewardship program (ASP) is sustained through improving antimicrobial prescribing by changing prescribing behavior. This requires a better understanding of hospital stakeholders' views regarding antimicrobial resistance (AMR), antimicrobial use and participation in ASP activities. Objectives: Identify perceptions and attitudes among physicians and pharmacists in a public hospital toward AMR, prescription and ASP. Methods: A questionnaire consisting of 45 items was distributed to physicians and pharmacists in a 320-bed public hospital. All responses were formatted into the Likert scale. Results: A total of 78 respondents (73% response rate) completed the questionnaire. The majority of the respondents perceived AMR within hospital as less of a severe problem, and factors outside hospital were considered to be greater contributors to AMR. In addition, interprofessional conflict was identified as a serious concern in relation to implementing ASP. Conclusion: This finding indicates the need to address existing perceptions and attitudes toward ASP activities that may hamper its successful implementation in Indonesia.
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Affiliation(s)
- Eko Setiawan
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, 4006, Australia.,Department of Clinical & Community Pharmacy, and Center for Medicines Information & Pharmaceutical Care (CMIPC), Faculty of Pharmacy, University of Surabaya, 60293, Surabaya, East Java, Indonesia
| | - Menino O Cotta
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, 4006, Australia
| | - Mohd Hafiz Abdul-Aziz
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, 4006, Australia
| | - Hernycane Sosilya
- Dr Mohamad Soewandhie Public Hospital, 60142, Surabaya, East Java, Indonesia
| | - Doddy Widjanarko
- Dr Mohamad Soewandhie Public Hospital, 60142, Surabaya, East Java, Indonesia.,Faculty of Medicine, Hang Tuah University, 60111, Surabaya, East Java, Indonesia
| | - Dian K Wardhani
- Dr Mohamad Soewandhie Public Hospital, 60142, Surabaya, East Java, Indonesia
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, 4006, Australia.,Departments of Pharmacy & Intensive Care Medicine, Royal Brisbane & Women's Hospital, Brisbane, 4029, Australia.,Division of Anesthesiology Critical Care Emergency & Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, 30029, France
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20
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Chalusa M, Khuluza F, Bandawe C. Determinants of clinician and patient to prescription of antimicrobials: Case of Mulanje, Southern Malawi. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0001274. [PMID: 36962685 PMCID: PMC10022363 DOI: 10.1371/journal.pgph.0001274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 10/21/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Antimicrobial resistance is an emerging problem in low- and middle-income countries. The problem is exacerbated by inappropriate prescription of antimicrobials. Factors that lead to overuse or inappropriate prescription of antimicrobials by the cadre of medical assistants, clinical technicians and clinical officers have received limited attention. This study investigated factors that influence prescription behaviours of antimicrobials among clinical officers in various health facilities in Mulanje district, Southern Malawi. METHODS Qualitative study design exploring determinants of antimicrobial prescription from May to October, 2019, was used. In-depth interviews (n = 18) and focus group discussions (n = 2) were conducted with medical assistant (MA), clinical technicians and clinical officers (CO) from four health facilities in Mulanje district. COs are licensed medical practitioners with an initial three-year training and one-year internship while MAs are licensed medical practitioners with initial two-year training and one year internship. Purposive sampling was done to arrive at a sample size of 30 health cadres. RESULTS Participants pointed out that patient preferences, beliefs and clinicians' inadequate education on this issue were among the factors that contribute to inappropriate antimicrobial prescription. 75% of clinicians showed lack of knowledge on the definition of antibiotic and antimicrobial resistance. CONCLUSION Inappropriate use of antimicrobials is facilitated by prescription decisions made by clinicians who are greatly influenced by their patients. Interventions aimed at improving antimicrobial prescription should target both clinicians and patients.
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Affiliation(s)
- Morris Chalusa
- Pathology Department, College of Medicine, University of Malawi, Blantyre, Malawi
- Mulanje District Hospital, Ministry of Health, Lilongwe, Malawi
| | - Felix Khuluza
- Pharmacy Department, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Chiwoza Bandawe
- Department of Mental Health, College of Medicine, University of Malawi, Blantyre, Malawi
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21
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Woods-Hill CZ, Xie A, Lin J, Wolfe HA, Plattner AS, Malone S, Chiotos K, Szymczak JE. OUP accepted manuscript. JAC Antimicrob Resist 2022; 4:dlab195. [PMID: 35098126 PMCID: PMC8794647 DOI: 10.1093/jacamr/dlab195] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Antimicrobial and diagnostic stewardship initiatives have become increasingly important in paediatric settings. The value of qualitative approaches to conduct stewardship work in paediatric patients is being increasingly recognized. This article seeks to provide an introduction to basic elements of qualitative study designs and provide an overview of how these methods have successfully been applied to both antimicrobial and diagnostic stewardship work in paediatric patients. A multidisciplinary team of experts in paediatric infectious diseases, paediatric critical care and qualitative methods has written a perspective piece introducing readers to qualitative stewardship work in children, intended as an overview to highlight the importance of such methods and as a starting point for further work. We describe key differences between qualitative and quantitative methods, and the potential benefits of qualitative approaches. We present examples of qualitative research in five discrete topic areas of high relevance for paediatric stewardship work: provider attitudes; provider prescribing behaviours; stewardship in low-resource settings; parents’ perspectives on stewardship; and stewardship work focusing on select high-risk patients. Finally, we explore the opportunities for multidisciplinary academic collaboration, incorporation of innovative scientific disciplines and young investigator growth through the use of qualitative research in paediatric stewardship. Qualitative approaches can bring rich insights and critically needed new information to antimicrobial and diagnostic stewardship efforts in children. Such methods are an important tool in the armamentarium against worsening antimicrobial resistance, and a major opportunity for investigators interested in moving the needle forward for stewardship in paediatric patients.
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Affiliation(s)
- Charlotte Z. Woods-Hill
- Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA
- University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, 3641 Locust Walk # 210, Philadelphia, PA 19104, USA
- Corresponding author. E-mail:
| | - Anping Xie
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 733 N Broadway, Baltimore, MD 21205, USA
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, 750 E Pratt St., Baltimore, MD 21202, USA
| | - John Lin
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, 660 S Euclid Ave, St Louis, MO 63110, USA
| | - Heather A. Wolfe
- Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA
- University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Alex S. Plattner
- Division of Pediatric Infectious Disease, Department of Pediatrics, Washington University School of Medicine, 660 S Euclid Ave, St Louis, MO 63110, USA
| | - Sara Malone
- Division of Pediatric Infectious Disease, Department of Pediatrics, Washington University School of Medicine, 660 S Euclid Ave, St Louis, MO 63110, USA
| | - Kathleen Chiotos
- Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA
- University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Julia E. Szymczak
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, 3641 Locust Walk # 210, Philadelphia, PA 19104, USA
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA
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22
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Leveraging implementation science to advance antibiotic stewardship practice and research. Infect Control Hosp Epidemiol 2021; 43:139-146. [PMID: 34852212 DOI: 10.1017/ice.2021.480] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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23
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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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24
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Pierantoni L, Lo Vecchio A, Lenzi J, Corsi V, Campana L, Luca Trobia G, Amendolea A, Di Felice B, Alighieri G, Fabrizio GC, Bisceglia M, Peia F, Chiale F, Bartolomei B, Siciliano C, Di Battista C, Passone E, di Giovanni C, Piergentili E, Donà D, Buonsenso D. Parents' Perspective of Antibiotic Usage in Children: A Nationwide Survey in Italy. Pediatr Infect Dis J 2021; 40:906-911. [PMID: 34437339 DOI: 10.1097/inf.0000000000003221] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Antibiotics represent the most widely prescribed drugs in children worldwide, both in hospital and community settings. A comprehensive approach to understanding the reasons and determinants of antibiotic prescription in the pediatric age is needed. This study aimed to assess parents' attitudes and perspectives about antibiotic use. METHODS Prospective observational study was conducted in all Italian Regions between February 1 and April 30, 2020, using a standardized questionnaire. RESULTS Six thousand six hundred twenty-five parents from all Italian regions completed the survey. Seventy-six percent of parents were aware that only bacteria are the target of antibiotics, but 92.9% knew that the antibiotic has no direct effect on fever. Antibiotic self-prescription (10.4%) or by remote consultation by phone call (19.9%) or message (9.6%) were relatively common. Ninety-three percent of parents were aware that excessive use of antibiotics could select resistant bacteria and 84.7% of them knew that they could actively fight antibiotic resistance. About two thirds of participants (66.1%) received information on antibiotic resistance from their family pediatrician. Parents born of Italy or those with lower income had a higher probability of having less information from pediatricians or knowledge of proper antibiotic use. DISCUSSION Our study suggests that parents' knowledge and attitudes toward antibiotic use and prescription are improving compared with previous studies, while there is still a gap regarding antibiotic resistance, particularly on practices that can reduce its burden. Our study's negative finding is that families from low-income settings or those born abroad have significantly more misconceptions about important antibiotic practices.
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Affiliation(s)
- Luca Pierantoni
- From the Pediatric Emergency Department, IRCSS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Andrea Lo Vecchio
- Department of Translational Medical Sciences-Section of Pediatrics, University of Naples Federico II, Napoli, Italy
| | - Jacopo Lenzi
- Dipartimento di Scienze Biomediche e Neuromotorie, Alma Mater Studiorum-Università di Bologna, Bologna, Italy
| | - Vincenza Corsi
- Department of Pediatrics, PO San Francesco Nuoro, Nuoro, Italy
| | - Lara Campana
- Department of Pediatrics, A. Cardarelli Hospital, Campobasso, Italy
| | - Gian Luca Trobia
- Pediatric and Pediatric Emergency Room Unit, "Cannizzaro" Emergency Hospital Catania, Catania, Italy
| | | | | | - Giovanni Alighieri
- Family Pediatrician, Unità di Pediatria e TIN, Azienda Ospedaliera Cardinale Giovanni Panico, Tricase, Italy
| | - Giovanna Carmela Fabrizio
- Unità Operativa Complessa Pediatria e Neonatologia Ospedale Madonna delle Grazie, ASM Matera, Matera, Italy
| | - Massimo Bisceglia
- Neonatal Intensive Care Unit, San Giovanni di Dio Hospital, Crotone, Calabria
| | - Francesco Peia
- Neonatal Intensive Care Unit and Paediatric Department, ASST Lecco, Lecco, Italy
| | - Federica Chiale
- Regina Margherita Children's Hospital, Postgraduation School of Pediatrics, AOU Città della Salute e della Scienza, University of Turin, Turin, Italy
| | | | | | | | - Eva Passone
- Department of Pediatrics, Azienda Ospedaliero-Universitaria "Santa Maria della Misericordia" di Udine, Friuli Venezia Giulia, Italy
| | | | | | - Daniele Donà
- Division of Pediatric Infectious Diseases, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Danilo Buonsenso
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Ge-melli IRCCS, Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
- Global Health Research Institute, Istituto di Igiene, Università Cattolica del Sacro Cuore, Roma, Italy
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25
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McIsaac W, Kukan S, Huszti E, Szadkowski L, O'Neill B, Virani S, Ivers N, Lall R, Toor N, Shah M, Alvi R, Bhatt A, Nakamachi Y, Morris AM. A pragmatic randomized trial of a primary care antimicrobial stewardship intervention in Ontario, Canada. BMC FAMILY PRACTICE 2021; 22:185. [PMID: 34525972 PMCID: PMC8442308 DOI: 10.1186/s12875-021-01536-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 09/01/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND More than 90% of antibiotics are prescribed in primary care, but 50% may be unnecessary. Reducing unnecessary antibiotic overuse is needed to limit antimicrobial resistance. We conducted a pragmatic trial of a primary care provider-focused antimicrobial stewardship intervention to reduce antibiotic prescriptions in primary care. METHODS Primary care practitioners from six primary care clinics in Toronto, Ontario were assigned to intervention or control groups to evaluate the effectiveness of a multi-faceted intervention for reducing antibiotic prescriptions to adults with respiratory and urinary tract infections. The intervention included provider education, clinical decision aids, and audit and feedback of antibiotic prescribing. The primary outcome was total antibiotic prescriptions for these infections. Secondary outcomes were delayed prescriptions, prescriptions longer than 7 days, recommended antibiotic use, and outcomes for individual infections. Generalized estimating equations were used to estimate treatment effects, adjusting for clustering by clinic and baseline differences. RESULTS There were 1682 encounters involving 54 primary care providers from January until May 31, 2019. In intervention clinics, the odds of any antibiotic prescription was reduced 22% (adjusted Odds Ratio (OR) = 0.78; 95% Confidence Interval (CI) = 0.64.0.96). The odds that a delay in filling a prescription was recommended was increased (adjusted OR=2.29; 95% CI=1.37, 3.83), while prescription durations greater than 7 days were reduced (adjusted OR=0.24; 95% CI=0.13, 0.43). Recommended antibiotic use was similar in control (85.4%) and intervention clinics (91.8%, p=0.37). CONCLUSIONS A community-based, primary care provider-focused antimicrobial stewardship intervention was associated with a reduced likelihood of antibiotic prescriptions for respiratory and urinary infections, an increase in delayed prescriptions, and reduced prescription durations. TRIAL REGISTRATION clinicaltrials.gov ( NCT03517215 ).
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Affiliation(s)
- Warren McIsaac
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada.
- Ray D. Wolfe Department of Family Medicine, Mount Sinai Hospital, Sinai Health, 60 Murray St, Toronto, ON, M5T 3L9, Canada.
| | - Sahana Kukan
- Ray D. Wolfe Department of Family Medicine, Mount Sinai Hospital, Sinai Health, 60 Murray St, Toronto, ON, M5T 3L9, Canada
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto, Canada
| | - Leah Szadkowski
- Biostatistics Research Unit, University Health Network, Toronto, Canada
| | - Braden O'Neill
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
- Department of Family and Community Medicine, St. Michael's Hospital, Toronto, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Sophia Virani
- Ray D. Wolfe Department of Family Medicine, Mount Sinai Hospital, Sinai Health, 60 Murray St, Toronto, ON, M5T 3L9, Canada
| | - Noah Ivers
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
- Department of Family Medicine, and Women's College Research Institute, Women's College Hospital, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Rosemarie Lall
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
- Platinum Medical, Scarborough Health Network Teaching Unit, Toronto, Canada
| | - Navsheer Toor
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
- Southlake Academic Family Health Team, Southlake Regional Health Centre, Newmarket, Toronto, Ontario, Canada
| | - Mruna Shah
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
- West Durham Family Health Team, Pickering, Toronto, Ontario, Canada
| | - Ruby Alvi
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
- Summerville Family Health Team, Mississauga, Ontario, Canada
| | - Aashka Bhatt
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
| | - Yoshiko Nakamachi
- Antimicrobial Stewardship Program, University Health Network, Toronto, Canada
| | - Andrew M Morris
- Antimicrobial Stewardship Program, University Health Network, Toronto, Canada
- Department of Medicine, Division of Infectious Diseases, Sinai Health, University Health Network, and University of Toronto, Toronto, Canada
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Goff DA, Prusakov P, Mangino JE, Sanchez PJ, Nwomeh B, Messina AP, Schellack N, Annor AS, Cassim A, Kolman S, Van Tonder L, Mawela D, Velaphi SC, Chirwa PL, Bergh D. International train the trainer neonatal antibiotic stewardship program for South African pharmacists. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2021. [DOI: 10.1002/jac5.1517] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Debra A. Goff
- Department of Pharmacy The Ohio State University Wexner Medical Center Columbus Ohio USA
- Division of Pharmacy Practice The Ohio State University College of Pharmacy Columbus Ohio USA
| | - Pavel Prusakov
- Department of Pharmacy Nationwide Children's Hospital Columbus Ohio USA
| | - Julie E. Mangino
- Department of Internal Medicine and Division of Infectious Diseases The Ohio State University and the Ohio State University Wexner Medical Center Columbus Ohio USA
| | - Pablo J. Sanchez
- Department of Pediatrics, Divisions of Neonatology and Pediatric Infectious Diseases Nationwide Children's Hospital, Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital Columbus Ohio USA
| | - Benedict Nwomeh
- Department of Pediatric Surgery Nationwide Children's Hospital Columbus Ohio USA
| | | | - Natalie Schellack
- Department of Pharmacology, Faculty of Health Sciences University of Pretoria Pretoria South Africa
| | - Ama S. Annor
- Department of Pharmacology, Faculty of Health Sciences University of Pretoria Pretoria South Africa
- Department of Pharmacy Dr. George Mukhari Academic Hospital Ga‐Rankuwa South Africa
| | - Azraa Cassim
- Department of Pharmacy Chris Hani Baragwanath Academic Hospital Soweto South Africa
| | - Sonya Kolman
- Department of Pharmacy Nelson Mandela Children's Hospital Johannesburg South Africa
- Department of Pharmacy and Pharmacology, School of Therapeutic Sciences, Faculty of Health Sciences University of the Witwatersrand Johannesburg South Africa
| | - Lindie Van Tonder
- Department of Pharmacy Netcare Femina Hospitals Ltd. Pretoria South Africa
| | - Dini Mawela
- Department of Paediatrics and Child Health Dr George Mukhari Academic Hospital Ga‐Rankuwa South Africa
| | - Sithembiso C. Velaphi
- Department of Pediatrics and Child Health, Chris Hani Baragwanath Academic Hospital, Faculty of Health Sciences University of the Witwatersrand Johannesburg South Africa
| | - Pinky Lea Chirwa
- Department of Neonatology Nelson Mandela Children's Hospital Johannesburg South Africa
| | - Dena Bergh
- Division of Infectious Diseases & HIV Medicine, Department of Medicine Groote Schuur Hospital University of Cape Town Cape Town South Africa
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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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28
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Johnson MC, Hulgan T, Cooke RG, Kleinpell R, Roumie C, Callaway-Lane C, Mitchell LD, Hathaway J, Dittus R, Staub M. Operationalising outpatient antimicrobial stewardship to reduce system-wide antibiotics for acute bronchitis. BMJ Open Qual 2021; 10:bmjoq-2020-001275. [PMID: 34210668 PMCID: PMC8252871 DOI: 10.1136/bmjoq-2020-001275] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 06/06/2021] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Antibiotics are not recommended for treatment of acute uncomplicated bronchitis (AUB), but are often prescribed (85% of AUB visits within the Veterans Affairs nationally). This quality improvement project aimed to decrease antibiotic prescribing for AUB in community-based outpatient centres from 65% to <32% by April 2020. METHODS From January to December 2018, community-based outpatient clinics' 6 months' average of prescribed antibiotics for AUB and upper respiratory infections was 63% (667 of 1054) and 64.6% (314 of 486) when reviewing the last 6 months. Seven plan-do-study-act (PDSA) cycles were implemented by an interprofessional antimicrobial stewardship team between January 2019 and March 2020. Balancing measures were a return patient phone call or visit within 4 weeks for the same complaint. Χ2 tests and statistical process control charts using Western Electric rules were used to analyse intervention data. RESULTS The AUB antibiotic prescribing rate decreased from 64.6% (314 of 486) in the 6 months prior to the intervention to 36.8% (154 of 418) in the final 6 months of the intervention. No change was seen in balancing measures. The largest reduction in antibiotic prescribing was seen after implementation of PDSA 6 in which 14 high prescribers were identified and targeted for individualised reviews of encounters of patients with AUB with an antimicrobial steward. CONCLUSIONS Operational implementation of successful stewardship interventions is challenging and differs from the traditional implementation study environment. As a nascent outpatient stewardship programme with limited resources and no additional intervention funding, we successfully reduced antibiotic prescribing from 64.6% to 36.8%, a reduction of 43% from baseline. The most success was seen with targeted education of high prescribers.
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Affiliation(s)
- Morgan Clouse Johnson
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System Nashville Campus, Nashville, Tennessee, USA
| | - Todd Hulgan
- Infectious Diseases, VA Tennessee Valley Healthcare System Nashville Campus, Nashville, Tennessee, USA.,Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Robin G Cooke
- Pharmacy, VA Tennessee Valley Healthcare System Nashville Campus, Nashville, Tennessee, USA
| | - Ruth Kleinpell
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System Nashville Campus, Nashville, Tennessee, USA.,School of Nursing, Vanderbilt University, Nashville, Tennessee, USA
| | - Christianne Roumie
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System Nashville Campus, Nashville, Tennessee, USA.,Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Carol Callaway-Lane
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System Nashville Campus, Nashville, Tennessee, USA
| | - Lauren D Mitchell
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System Nashville Campus, Nashville, Tennessee, USA
| | - Jacob Hathaway
- Primary Care, VA Tennessee Valley Healthcare System Nashville Campus, Nashville, Tennessee, USA
| | - Robert Dittus
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System Nashville Campus, Nashville, Tennessee, USA.,Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Milner Staub
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System Nashville Campus, Nashville, Tennessee, USA.,Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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29
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Association between antibiotic prescribing and visit duration among patients with respiratory tract infections. Infect Control Hosp Epidemiol 2021; 43:1238-1241. [PMID: 34112273 DOI: 10.1017/ice.2021.182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Time constraints have been suggested as a potential driver of antibiotic overuse for acute respiratory tract infections. In this cross-sectional analysis of national data from visits to offices and emergency departments, we identified no statistically significant association between antibiotic prescribing and the duration of visits for acute respiratory tract infections.
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30
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Woods CJ, Morrice Z, Francis NA, Little P, Verheij T, Leydon GM. Parent and Clinician Views of Managing Children with Symptoms of a Lower Respiratory Tract Infection and Their Influence upon Decisions to Take Part in a Placebo-Controlled Randomised Control Trial. Antibiotics (Basel) 2021; 10:356. [PMID: 33800619 PMCID: PMC8065881 DOI: 10.3390/antibiotics10040356] [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: 02/05/2021] [Revised: 03/20/2021] [Accepted: 03/26/2021] [Indexed: 11/17/2022] Open
Abstract
Children presenting with uncomplicated lower respiratory tract infections (LRTIs) commonly receive antibiotics despite public campaigns on antibiotic resistance. Qualitative interview studies were nested in a placebo-controlled trial of amoxicillin for LRTI in children. Thirty semi-structured telephone interviews were conducted with sixteen parents and fourteen clinicians to explore views of management and decisions to participate in the trial. All interviews were audio-recorded, transcribed and analysed using thematic analysis. Parents found it difficult to interpret symptoms and signs, and commonly used the type of cough (based on sound) to judge severity, highlighting the importance of better information to support parents. Provision of a clinical examination and reassurance regarding illness severity were key motivations for consulting. Many parents now acknowledge that antibiotics should only be used when 'necessary', and clinicians reported noticing a shift in parent attitudes with less demand for antibiotics and greater satisfaction with clinical assessment, reassurance and advice. Decisions to take part in the trial were influenced by the perceived risks associated with allocation to a placebo, and concerns about unnecessary use of antibiotics. Clear communication about self-management and safety-netting were identified as important when implementing 'no antibiotic' prescribing strategies to reassure parents and to support prescribing decisions.
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Affiliation(s)
- Catherine J. Woods
- Primary Care Research Centre, School of Primary Care, Population Sciences and Medical Education, University of Southampton, Aldermoor Close, Southampton SO16 5ST, UK; (Z.M.); (N.A.F.); (P.L.); (G.M.L.)
| | - Zoe Morrice
- Primary Care Research Centre, School of Primary Care, Population Sciences and Medical Education, University of Southampton, Aldermoor Close, Southampton SO16 5ST, UK; (Z.M.); (N.A.F.); (P.L.); (G.M.L.)
| | - Nick A. Francis
- Primary Care Research Centre, School of Primary Care, Population Sciences and Medical Education, University of Southampton, Aldermoor Close, Southampton SO16 5ST, UK; (Z.M.); (N.A.F.); (P.L.); (G.M.L.)
| | - Paul Little
- Primary Care Research Centre, School of Primary Care, Population Sciences and Medical Education, University of Southampton, Aldermoor Close, Southampton SO16 5ST, UK; (Z.M.); (N.A.F.); (P.L.); (G.M.L.)
| | - Theo Verheij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, 3584 CG Utrecht, The Netherlands;
| | - Geraldine M. Leydon
- Primary Care Research Centre, School of Primary Care, Population Sciences and Medical Education, University of Southampton, Aldermoor Close, Southampton SO16 5ST, UK; (Z.M.); (N.A.F.); (P.L.); (G.M.L.)
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Mohareb AM, Letourneau AR, Sánchez SM, Walensky RP, Hyle EP. Addressing Antibiotic Overuse in the Outpatient Setting: Lessons From Behavioral Economics. Mayo Clin Proc 2021; 96:537-542. [PMID: 33673906 PMCID: PMC7944878 DOI: 10.1016/j.mayocp.2020.10.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 10/06/2020] [Accepted: 10/28/2020] [Indexed: 02/01/2023]
Affiliation(s)
- Amir M Mohareb
- Medical Practice Evaluation Center, Massachusetts General Hospital, MA; Division of Infectious Diseases, Massachusetts General Hospital, MA; Harvard Medical School, Boston, MA.
| | - Alyssa R Letourneau
- Division of Infectious Diseases, Massachusetts General Hospital, MA; Harvard Medical School, Boston, MA
| | - Sarimer M Sánchez
- Division of Infectious Diseases, Massachusetts General Hospital, MA; Harvard Medical School, Boston, MA
| | - Rochelle P Walensky
- Medical Practice Evaluation Center, Massachusetts General Hospital, MA; Division of Infectious Diseases, Massachusetts General Hospital, MA; Harvard Medical School, Boston, MA
| | - Emily P Hyle
- Medical Practice Evaluation Center, Massachusetts General Hospital, MA; Division of Infectious Diseases, Massachusetts General Hospital, MA; Harvard Medical School, Boston, MA
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32
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Meyer P, Hill C, Baker D. Standardizing Nurse Leader Safety Rounds to Promote Highly Reliable Care. J Nurs Care Qual 2021; 35:252-257. [PMID: 32433149 DOI: 10.1097/ncq.0000000000000445] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Despite decades of intensive resource allocation to eliminate preventable harm and increase high reliability in the hospital, the prevalence of serious harm remains consistent. LOCAL PROBLEM A hospital reduced targeted preventable harms using audit and feedback (A&F) but failed to globally reduce harm or increase proactive awareness. Nurse leaders lacked a defined process for identifying errors, mitigating risk, and teaching systems thinking to influence resiliency among teams. METHODS Nurse leaders underwent A&F of daily safety rounds. Adherence data on frequency, high-quality, and high-reliability organizational (HRO) leader practice standards and precursor incident reporting rates were trended. RESULTS Rounding practice adherence increased for the following defined standards: frequency (63%-79%); high quality (50%-90%); and HRO leadership (0%-67%). Precursor incident reporting rates increased 25%. CONCLUSIONS A&F reinforced quality and accountability for daily safety rounds. HRO theory-guided feedback offered an innovative way to translate HRO influence into nurse leader practice.
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Affiliation(s)
- Priya Meyer
- Legacy Health, Portland, Oregon (Dr Meyer); Randall Children's Hospital at Legacy Health, Portland, Oregon (Ms Hill); and Johns Hopkins Health System and Johns Hopkins University School of Nursing, Baltimore, Maryland (Dr Baker)
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33
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Same RG, Hsu AJ, Cosgrove SE, Klein EY, Amoah J, Hersh AL, Kronman MP, Tamma PD. Antibiotic-Associated Adverse Events in Hospitalized Children. J Pediatric Infect Dis Soc 2021; 10:622-628. [PMID: 33452808 PMCID: PMC8162628 DOI: 10.1093/jpids/piaa173] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 12/23/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Antibiotic-associated adverse events (AEs) in hospitalized children have not been comprehensively characterized. METHODS We conducted a retrospective observational study of children hospitalized at The Johns Hopkins Hospital receiving ≥24 hours of systemic antibiotics. Consensus regarding antibiotic-associated AE definitions was established by 5 infectious diseases specialists prior to data collection. Two physicians reviewed potential AEs and determined whether they were more likely than not related to antibiotics after comprehensive manual chart review. Inpatient and post-discharge AEs were identified using the Epic Care Everywhere network. AEs evaluated from the initiation of antibiotics until 30 days after antibiotic completion included gastrointestinal, hematologic, hepatobiliary, renal, neurologic, dermatologic, cardiac, myositis, vascular access device-related events, and systemic reactions. Ninety-day AEs included Clostridioides difficile infections, multidrug-resistant organism infections, and clinically significant candidal infections. The impact of AEs was categorized as necessitating additional diagnostic testing, changes in medications, unplanned medical encounters, prolonged or new hospitalizations, or death. RESULTS Among 400 antibiotic courses, 21% were complicated by at least one AE and 30% occurred post-discharge. Each additional day of antibiotics was associated with a 7% increased odds of an AE. Of courses complicated by an AE, 66% required further intervention. Hematologic, gastrointestinal, and renal AEs were the most common, accounting for 31%, 15%, and 11% of AEs, respectively. AEs complicated 35%, 35%, 19%, and 18% of courses of piperacillin-tazobactam, tobramycin, ceftazidime, and vancomycin, respectively. CONCLUSIONS More than 1 in 5 courses of antibiotics administered to hospitalized children are complicated by AEs. Clinicians should weigh the risk of harm against expected benefit when prescribing antibiotics.
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Affiliation(s)
- Rebecca G Same
- Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA,Corresponding Author: Rebecca G. Same, MD, Department of Pediatrics, Washington University School of Medicine in St. Louis, Campus Box 8116, One Children’s Place, St. Louis, MO 63110, USA. E-mail:
| | - Alice J Hsu
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Sara E Cosgrove
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Eili Y Klein
- Department of Emergency Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Joe Amoah
- Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Adam L Hersh
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Matthew P Kronman
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - Pranita D Tamma
- Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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34
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Patterson PP, Ellingson KD, Backus D, Schmitz E, Matesan M. A syndrome-based approach to antimicrobial stewardship in an Arizona skilled nursing facility-Moving the needle through quality improvement. Am J Infect Control 2020; 48:1537-1539. [PMID: 32763349 DOI: 10.1016/j.ajic.2020.07.038] [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] [Received: 11/22/2019] [Revised: 07/20/2020] [Accepted: 07/23/2020] [Indexed: 10/23/2022]
Abstract
In 2015, an Arizona skilled nursing facility implemented an antibiotic stewardship protocol targeting unnecessary prescribing for suspect urinary tract infection. The protocol emphasized auditing of culturing and prescribing practices, feedback to prescribers, engagement of clinical staff, and educational in-services. Between Quarter 4 of 2014 (baseline) and Quarter 1 of 2017, urine culturing, days of antibiotic therapy for suspect urinary tract infection, and Clostridiodes difficile infections per 1,000 resident-days decreased by >50% with no urosepsis events.
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35
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Goggin K, Hurley EA, Bradley-Ewing A, Bickford C, Lee BR, Pina K, De Miranda ED, Mackenzie A, Yu D, Weltmer K, Linnemayr S, Butler CC, Miller M, Newland JG, Myers AL. Reductions in Parent Interest in Receiving Antibiotics following a 90-Second Video Intervention in Outpatient Pediatric Clinics. J Pediatr 2020; 225:138-145.e1. [PMID: 32553835 PMCID: PMC7529942 DOI: 10.1016/j.jpeds.2020.06.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 05/05/2020] [Accepted: 06/09/2020] [Indexed: 01/09/2023]
Abstract
OBJECTIVES To assess the impact of a 90-second animated video on parents' interest in receiving an antibiotic for their child. STUDY DESIGN This pre-post test study enrolled English and Spanish speaking parents (n = 1051) of children ages 1-5 years presenting with acute respiratory tract infection symptoms. Before meeting with their provider, parents rated their interest in receiving an antibiotic for their child, answered 6 true/false antibiotic knowledge questions, viewed the video, and then rated their antibiotic interest again. Parents rated their interest in receiving an antibiotic using a visual analogue scale ranging from 0 to 100, with 0 being "I definitely do not want an antibiotic," 50 "Neutral," and 100 "I absolutely want an antibiotic." RESULTS Parents were 84% female, with a mean age of 32 ± 6.0, 26.0% had a high school education or less, 15% were black, and 19% were Hispanic. After watching the video, parents' average antibiotic interest ratings decreased by 10 points (mean, 57.0 ± 20 to M ± 21; P < .0001). Among parents with the highest initial antibiotic interest ratings (≥60), even greater decreases were observed (83.0 ± 12.0 to 63.4 ± 22; P < .0001) with more than one-half (52%) rating their interest in the low or neutral ranges after watching the video. CONCLUSIONS A 90-second video can decrease parents' interest in receiving antibiotics, especially among those with higher baseline interest. This scalable intervention could be used in a variety of settings to reduce parents' interest in receiving antibiotics. TRIAL REGISTRATION ClinicalTrials.gov: NCT03037112.
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Affiliation(s)
- Kathy Goggin
- Health Services and Outcomes Research, Children's Mercy Hospitals and Clinics, Kansas City, MO; University of Missouri - Kansas City School of Medicine, Kansas City, MO; University of Missouri - Kansas City School of Pharmacy, Kansas City, MO.
| | - Emily A. Hurley
- Health Services and Outcomes Research, Children’s Mercy Hospitals and Clinics, Kansas City
| | - Andrea Bradley-Ewing
- Health Services and Outcomes Research, Children’s Mercy Hospitals and Clinics, Kansas City
| | - Carey Bickford
- Health Services and Outcomes Research, Children’s Mercy Hospitals and Clinics, Kansas City
| | - Brian R. Lee
- Health Services and Outcomes Research, Children’s Mercy Hospitals and Clinics, Kansas City,University of Missouri – Kansas City School of Medicine, Kansas City
| | - Kimberly Pina
- Health Services and Outcomes Research, Children’s Mercy Hospitals and Clinics, Kansas City
| | | | - Alexander Mackenzie
- Health Services and Outcomes Research, Children’s Mercy Hospitals and Clinics, Kansas City
| | - David Yu
- Sunflower Medical Group, Kansas City
| | - Kirsten Weltmer
- University of Missouri – Kansas City School of Medicine, Kansas City
| | | | | | - Melissa Miller
- University of Missouri – Kansas City School of Medicine, Kansas City,Emergency Department, Children’s Mercy, Kansas City
| | - Jason G. Newland
- Pediatric Infectious Disease, St. Louis Children’s Hospital, St. Louis
| | - Angela L. Myers
- University of Missouri – Kansas City School of Medicine, Kansas City,Pediatric Infectious Diseases, Children’s Mercy, Kansas City
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36
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Diaz MCG, Handy LK, Crutchfield JH, Cadilla A, Hossain J, Werk LN. Impact of a Personalized Audit and Feedback Intervention on Antibiotic Prescribing Practices for Outpatient Pediatric Community-Acquired Pneumonia. Clin Pediatr (Phila) 2020; 59:988-994. [PMID: 32486840 DOI: 10.1177/0009922820928054] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Antibiotic choice for pediatric community-acquired pneumonia (CAP) varies widely. We aimed to determine the impact of a 6-month personalized audit and feedback program on primary care providers' antibiotic prescribing practices for CAP. Participants in the intervention group received monthly personalized feedback. We then analyzed enrolled providers' CAP antibiotic prescribing practices. Participants diagnosed 316 distinct cases of CAP (214 control, 102 intervention); among these 316 participants, 301 received antibiotics (207 control, 94 intervention). In patients ≥5 years, the intervention group had fewer non-guideline-concordant antibiotics prescribed (22/103 [21.4%] control; 3/51 [5.9%] intervention, P < .05) and received more of the guideline-concordant antibiotics (amoxicillin and azithromycin). Personalized, scheduled audit and feedback in the outpatient setting was feasible and had a positive impact on clinician's selection of guideline-recommended antibiotics. Audit and feedback should be combined with other antimicrobial stewardship interventions to improve guideline adherence in the management of outpatient CAP.
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Affiliation(s)
| | - Lori K Handy
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | | | - Jobayer Hossain
- Nemours/Alfred I. du Pont Hospital for Children, Wilmington, DE, USA
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37
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Redding LE, Muller BM, Szymczak JE. Small and Large Animal Veterinarian Perceptions of Antimicrobial Use Metrics for Hospital-Based Stewardship in the United States. Front Vet Sci 2020; 7:582. [PMID: 33102546 PMCID: PMC7505943 DOI: 10.3389/fvets.2020.00582] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 07/20/2020] [Indexed: 12/23/2022] Open
Abstract
Background: Robust measurement and tracking of antimicrobial use (AMU) is a fundamental component of stewardship interventions. Feeding back AMU metrics to individual clinicians is a common approach to changing prescribing behavior. Metrics must be meaningful and comprehensible to clinicians. Little is known about how veterinary clinicians working in the United States (US) hospital setting think about AMU metrics for antimicrobial stewardship. Objective: To identify hospital-based veterinary clinicians' attitudes toward audit and feedback of AMU metrics, their perceptions of different AMU metrics, and their response to receiving an individualized prescribing report. Methods: Semi-structured interviews were conducted with veterinarians working at two hospitals in the Eastern US. Interviews elicited perceptions of antimicrobial stewardship in veterinary medicine. Respondents were shown a personalized AMU Report characterizing their prescribing patterns relative to their peers and were asked to respond. Interviews were recorded, transcribed, and analyzed using the framework method with matrices. Results: Semi-structured interviews were conducted with 34 veterinary clinicians (22 small animal and 12 large animal). Respondents generally felt positive about the reports and were interested in seeing how their prescribing compared to that of their peers. Many respondents expressed doubt that the reports accurately captured the complexities of their prescribing decisions and found metrics associated with animal daily doses (ADDs) confusing. Only 13 (38.2%) respondents felt the reports would change how they used antimicrobials. When asked how the impact of the reports could be optimized, respondents recommended providing a more detailed explanation of how the AMU metrics were derived, education prior to report roll-out, guidance on how to interpret the metrics, and development of meaningful benchmarks for goal-setting. Conclusions: These findings provide important insight that can be used to design veterinary-specific AMU metrics as part of a stewardship intervention that are meaningful to clinicians and more likely to promote judicious prescribing.
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Affiliation(s)
- Laurel E. Redding
- Department of Clinical Sciences, University of Pennsylvania School of Veterinary Medicine, Philadelphia, PA, United States
| | - Brandi M. Muller
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Julia E. Szymczak
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
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38
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Hamdy RF, Katz SE. The Key to Antibiotic Stewardship Is Combining Interventions. Pediatrics 2020; 146:peds.2020-012922. [PMID: 32747474 DOI: 10.1542/peds.2020-012922] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/19/2020] [Indexed: 11/24/2022] Open
Affiliation(s)
- Rana F Hamdy
- Division of Infectious Diseases, Children's National Hospital, Washington, District of Columbia; .,Department of Pediatrics, School of Medicine, The George Washington University, Washington, District of Columbia; and
| | - Sophie E Katz
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
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39
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Kronman MP, Gerber JS, Grundmeier RW, Zhou C, Robinson JD, Heritage J, Stout J, Burges D, Hedrick B, Warren L, Shalowitz M, Shone LP, Steffes J, Wright M, Fiks AG, Mangione-Smith R. Reducing Antibiotic Prescribing in Primary Care for Respiratory Illness. Pediatrics 2020; 146:e20200038. [PMID: 32747473 PMCID: PMC7461202 DOI: 10.1542/peds.2020-0038] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/15/2020] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND One-third of outpatient antibiotic prescriptions for pediatric acute respiratory tract infections (ARTIs) are inappropriate. We evaluated a distance learning program's effectiveness for reducing outpatient antibiotic prescribing for ARTI visits. METHODS In this stepped-wedge clinical trial run from November 2015 to June 2018, we randomly assigned 19 pediatric practices belonging to the Pediatric Research in Office Settings Network or the NorthShore University HealthSystem to 4 wedges. Visits for acute otitis media, bronchitis, pharyngitis, sinusitis, and upper respiratory infection for children 6 months to <11 years old without recent antibiotic use were included. Clinicians received the intervention as 3 program modules containing online tutorials and webinars on evidence-based communication strategies and antibioti c prescribing, booster video vignettes, and individualized antibiotic prescribing feedback reports over 11 months. The primary outcome was overall antibiotic prescribing rates for all ARTI visits. Mixed-effects logistic regression compared prescribing rates during each program module and a postintervention period to a baseline control period. Odds ratios were converted to adjusted rate ratios (aRRs) for interpretability. RESULTS Among 72 723 ARTI visits by 29 762 patients, intention-to-treat analyses revealed a 7% decrease in the probability of antibiotic prescribing for ARTI overall between the baseline and postintervention periods (aRR 0.93; 95% confidence interval [CI], 0.90-0.96). Second-line antibiotic prescribing decreased for streptococcal pharyngitis (aRR 0.66; 95% CI, 0.50-0.87) and sinusitis (aRR 0.59; 95% CI, 0.44-0.77) but not for acute otitis media (aRR 0.93; 95% CI, 0.83-1.03). Any antibiotic prescribing decreased for viral ARTIs (aRR 0.60; 95% CI, 0.51-0.70). CONCLUSIONS This program reduced antibiotic prescribing during outpatient ARTI visits; broader dissemination may be beneficial.
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Affiliation(s)
- Matthew P Kronman
- Department of Pediatrics, University of Washington, Seattle, Washington;
- Seattle Children's Research Institute, Seattle, Washington
| | - Jeffrey S Gerber
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Robert W Grundmeier
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Chuan Zhou
- Department of Pediatrics, University of Washington, Seattle, Washington
- Seattle Children's Research Institute, Seattle, Washington
| | - Jeffrey D Robinson
- Department of Communication, College of Liberal Arts and Sciences, Portland State University, Portland, Oregon
| | - John Heritage
- Department of Sociology, University of California, Los Angeles, Los Angeles, California
| | - James Stout
- Department of Pediatrics, University of Washington, Seattle, Washington
| | - Dennis Burges
- Department of Pediatrics, University of Washington, Seattle, Washington
| | - Benjamin Hedrick
- Department of Pediatrics, University of Washington, Seattle, Washington
| | - Louise Warren
- Department of Pediatrics, University of Washington, Seattle, Washington
| | | | - Laura P Shone
- Primary Care Research, American Academy of Pediatrics, Itasca, Illinois; and
| | - Jennifer Steffes
- Primary Care Research, American Academy of Pediatrics, Itasca, Illinois; and
| | - Margaret Wright
- Primary Care Research, American Academy of Pediatrics, Itasca, Illinois; and
| | - Alexander G Fiks
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Primary Care Research, American Academy of Pediatrics, Itasca, Illinois; and
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40
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Zetts RM, Stoesz A, Garcia AM, Doctor JN, Gerber JS, Linder JA, Hyun DY. Primary care physicians' attitudes and perceptions towards antibiotic resistance and outpatient antibiotic stewardship in the USA: a qualitative study. BMJ Open 2020; 10:e034983. [PMID: 32665343 PMCID: PMC7365421 DOI: 10.1136/bmjopen-2019-034983] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 05/01/2020] [Accepted: 06/08/2020] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES At least 30% of outpatient antibiotic prescriptions are unnecessary. Outpatient antibiotic stewardship is needed to improve prescribing and address the threat of antibiotic resistance. A better understanding of primary care physicians (PCPs) attitudes towards antibiotic prescribing and outpatient antibiotic stewardship is needed to identify barriers to stewardship implementation and help tailor stewardship strategies. The aim of this study was to assess PCPs current attitudes towards antibiotic resistance, inappropriate antibiotic prescribing and the feasibility of outpatient stewardship efforts. DESIGN Eight focus groups with PCPs were conducted by an independent moderator using a moderator guide. Focus groups were audio recorded, transcribed and coded for major themes using deductive and inductive content analysis methods. SETTING Focus groups were conducted in four US cities: Philadelphia, Birmingham, Chicago and Los Angeles. PARTICIPANTS Two focus groups were conducted in each city-one with family medicine and internal medicine physicians and one with paediatricians. A total of 26 family medicine/internal medicine physicians and 26 paediatricians participated. RESULTS Participants acknowledged that resistance is an important public health issue, but not as important as other pressing problems (eg, obesity, opioids). Many considered resistance to be more of a hospital issue. While participants recognised inappropriate prescribing as a problem in outpatient settings, many felt that the key drivers were non-primary care settings (eg, urgent care clinics, retail clinics) and patient demand. Participants reacted positively to stewardship efforts aimed at educating patients and clinicians. They questioned the validity of antibiotic prescribing metrics. This scepticism was due to a number of factors, including the feasibility of capturing prescribing quality, a belief that physicians will 'game the system' to improve their measures, and dissatisfaction and distrust of quality measurement in general. CONCLUSIONS Stakeholders will need to consider physician attitudes and beliefs about antibiotic stewardship when implementing interventions aimed at improving prescribing.
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Affiliation(s)
- Rachel M Zetts
- Antibiotic Resistance Project, The Pew Charitable Trusts, Washington, District of Columbia, USA
| | - Andrea Stoesz
- Antibiotic Resistance Project, The Pew Charitable Trusts, Washington, District of Columbia, USA
| | - Andrea M Garcia
- Health & Science, American Medical Association, Chicago, Illinois, USA
| | - Jason N Doctor
- Department of Health Policy and Management, Sol Price School of Public Policy, University of Southern California, Los Angeles, California, USA
| | - Jeffrey S Gerber
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jeffrey A Linder
- Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - David Y Hyun
- Antibiotic Resistance Project, The Pew Charitable Trusts, Washington, District of Columbia, USA
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41
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Zetts RM, Garcia AM, Doctor JN, Gerber JS, Linder JA, Hyun DY. Primary Care Physicians' Attitudes and Perceptions Towards Antibiotic Resistance and Antibiotic Stewardship: A National Survey. Open Forum Infect Dis 2020; 7:ofaa244. [PMID: 32782909 PMCID: PMC7406830 DOI: 10.1093/ofid/ofaa244] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 06/11/2020] [Indexed: 01/08/2023] Open
Abstract
Background Outpatient antibiotic stewardship is needed to reduce inappropriate prescribing and minimize the development of resistant bacteria. We assessed primary care physicians’ perceptions of antibiotic resistance, antibiotic use, and the need for stewardship activities. Methods We conducted a national online survey of 1550 internal, family, and pediatric medicine physicians in the United States recruited from an opt-in panel of healthcare professionals. Descriptive statistics were generated for respondent demographics and question responses. Responses were also stratified by geographic region and medical specialty, with a χ 2 test used to assess for differences. Results More respondents agreed that antibiotic resistance was a problem in the United States (94%) than in their practice (55%) and that inappropriate antibiotic prescribing was a problem in outpatient settings (91%) than in their practice (37%). In addition, 60% agreed that they prescribed antibiotics more appropriately than their peers. Most respondents (91%) believed that antibiotic stewardship was appropriate in office-based practices, but they ranked antibiotic resistance as less important than other public health issues such as obesity, diabetes, opioids, smoking, and vaccine hesitancy. Approximately half (47%) believed they would need a lot of help to implement stewardship. Respondents indicated that they were likely to implement antibiotic stewardship efforts in response to feedback or incentives provided by payers or health departments. Conclusions Primary care physicians generally did not recognize antibiotic resistance and inappropriate prescribing as issues in their practice. This poses a challenge for the success of outpatient stewardship. Healthcare stakeholders will need to explore opportunities for feedback and incentive activities to encourage stewardship uptake.
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Affiliation(s)
- Rachel M Zetts
- The Pew Charitable Trusts, Washington, District of Columbia, USA
| | | | - Jason N Doctor
- Department of Health Policy and Management, Sol Price School of Public Policy, University of Southern California, Los Angeles, California, USA
| | - Jeffrey S Gerber
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jeffrey A Linder
- Division of General Internal Medicine and Geriatrics, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - David Y Hyun
- The Pew Charitable Trusts, Washington, District of Columbia, USA
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42
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Penza KS, Murray MA, Myers JF, Furst JW, Pecina JL. Management of Acute Sinusitis via e-Visit. Telemed J E Health 2020; 27:532-536. [PMID: 32522103 DOI: 10.1089/tmj.2020.0047] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Acute sinusitis is the most common diagnosis in online health care delivery and is the diagnosis most associated with antibiotic prescriptions in the outpatient setting. Few studies have evaluated the effectiveness of managing sinusitis through e-visit in terms of antibiotic prescribing and follow-up rates. Introduction: The purpose of this study was to investigate whether e-visits for the management of acute sinusitis have equivalent clinical outcomes for patients when compared with face-to-face (F2F) visits and nurse-administered phone protocols in terms of antibiotic prescriptions and follow-up rates. Materials and Methods: A retrospective chart review was conducted on empaneled primary care patients between the ages of 18 and 75 years who had a clinical encounter for acute sinusitis at Mayo Clinic Rochester through e-visit, retail health clinic, or phone protocol. Initial antibiotic prescribing rates and follow-up rates for each encounter type were compared. Results: Both e-visit and phone protocol sinusitis encounters were less likely to result in initial treatment with an antibiotic than an F2F visit (84/150 [56%] e-visit, 92/150 [61%] phone, 108/150 [72%]; p = 0.01). There was no significant difference in follow-up rate between e-visits and F2F (27/150 [18%] vs. 21/150 [14%]; p = 0.34), and e-visits had significantly fewer follow-up visits than phone protocol (27/150 [18%] vs. 53/150 [35%]; p < 0.001). Conclusions: e-Visits are an effective modality to care for patients with acute sinusitis, offering equivalent or lower treatment and follow-up rates than more traditional avenues such as F2F visit at a retail clinic and phone protocol.
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Affiliation(s)
- Kristine S Penza
- Department of Family Medicine, Mayo Clinic Express Care, Division of Primary Care in Rochester, Rochester, Minnesota, USA.,Depatment of Family Medicine, Division of Primary Care in Rochester, Rochester, Minnesota, USA
| | - Martha A Murray
- Department of Family Medicine, Mayo Clinic Express Care, Division of Primary Care in Rochester, Rochester, Minnesota, USA.,Depatment of Family Medicine, Division of Primary Care in Rochester, Rochester, Minnesota, USA
| | - Jane F Myers
- Depatment of Family Medicine, Division of Primary Care in Rochester, Rochester, Minnesota, USA
| | - Joseph W Furst
- Depatment of Family Medicine, Division of Primary Care in Rochester, Rochester, Minnesota, USA
| | - Jennifer L Pecina
- Depatment of Family Medicine, Division of Primary Care in Rochester, Rochester, Minnesota, USA
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43
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Klein EY, Schueller E, Tseng KK, Morgan DJ, Laxminarayan R, Nandi A. The Impact of Influenza Vaccination on Antibiotic Use in the United States, 2010-2017. Open Forum Infect Dis 2020; 7:ofaa223. [PMID: 32665959 PMCID: PMC7336555 DOI: 10.1093/ofid/ofaa223] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 06/02/2020] [Indexed: 12/31/2022] Open
Abstract
Background Influenza, which peaks seasonally, is an important driver for antibiotic prescribing. Although influenza vaccination has been shown to reduce severe illness, evidence of the population-level effects of vaccination coverage on rates of antibiotic prescribing in the United States is lacking. Methods We conducted a retrospective analysis of influenza vaccination coverage and antibiotic prescribing rates from 2010 to 2017 across states in the United States, controlling for differences in health infrastructure and yearly vaccine effectiveness. Using data from IQVIA’s Xponent database and the US Centers for Disease Control and Prevention’s FluVaxView, we employed fixed-effects regression analysis to analyze the relationship between influenza vaccine coverage rates and the number of antibiotic prescriptions per 1000 residents from January to March of each year. Results We observed that, controlling for socioeconomic differences, access to health care, childcare centers, climate, vaccine effectiveness, and state-level differences, a 10–percentage point increase in the influenza vaccination rate was associated with a 6.5% decrease in antibiotic use, equivalent to 14.2 (95% CI, 6.0–22.4; P = .001) fewer antibiotic prescriptions per 1000 individuals. Increased vaccination coverage reduced prescribing rates the most in the pediatric population (0–18 years), by 15.2 (95% CI, 9.0–21.3; P < .001) or 6.0%, and the elderly (aged 65+), by 12.8 (95% CI, 6.5–19.2; P < .001) or 5.2%. Conclusions Increased influenza vaccination uptake at the population level is associated with state-level reductions in antibiotic use. Expanding influenza vaccination could be an important intervention to reduce unnecessary antibiotic prescribing.
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Affiliation(s)
- Eili Y Klein
- Center for Disease Dynamics, Economics & Policy, Washington, DC, USA.,Johns Hopkins University, Baltimore, Maryland, USA
| | - Emily Schueller
- Center for Disease Dynamics, Economics & Policy, Washington, DC, USA
| | - Katie K Tseng
- Center for Disease Dynamics, Economics & Policy, Washington, DC, USA
| | - Daniel J Morgan
- University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Ramanan Laxminarayan
- Center for Disease Dynamics, Economics & Policy, Washington, DC, USA.,Princeton University, Princeton, New Jersey, USA.,University of Washington, Seattle, Washington, USA
| | - Arindam Nandi
- Center for Disease Dynamics, Economics & Policy, Washington, DC, USA
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44
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Kim Y, Dillard JP, Smith RA. Communicating Antibiotic Stewardship: Emotional Responses and Their Impact on Adherence. HEALTH COMMUNICATION 2020; 35:861-871. [PMID: 31007076 DOI: 10.1080/10410236.2019.1598615] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Although watchful watching has been recommended as a means of reducing unnecessary use of antibiotics, nonadherence has frequently been observed. Drawing from appraisal theories of emotion, this study (n = 579) examined (a) the factors that shape pediatric caregivers' emotional experiences in the medical contexts and (b) the influence of emotions on (non)adherence behavioral intentions. Caregivers reported more intense negative emotions and less intense positive emotions following watchful waiting advice versus receiving an antibiotic prescription. The differences were mostly driven by false beliefs about antibiotics' effectiveness. Emotional responses predicted intentions to adhere to watchful waiting advice (e.g., counterargue and seek another healthcare provider), with anger being the most consistent determinant of these outcomes. Improving antibiotic stewardship can be achieved by educational efforts to correct false beliefs and by training healthcare providers to manage caregiver emotions.
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Affiliation(s)
- Youllee Kim
- Department of Communication Arts and Sciences, The Pennsylvania State University
| | - James Price Dillard
- Department of Communication Arts and Sciences, The Pennsylvania State University
| | - Rachel A Smith
- Department of Communication Arts and Sciences, The Pennsylvania State University
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45
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Pulia MS, Hesse S, Schwei RJ, Schulz LT, Sethi A, Hamedani A. Inappropriate Antibiotic Prescribing for Respiratory Conditions Does Not Improve Press Ganey Patient Satisfaction Scores in the Emergency Department. Open Forum Infect Dis 2020; 7:ofaa214. [PMID: 32617378 PMCID: PMC7320835 DOI: 10.1093/ofid/ofaa214] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 06/02/2020] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND The literature has mixed results regarding the relationship between antibiotic prescribing and patient satisfaction in the emergency department (ED) for antibiotic-inappropriate respiratory diagnoses. The objective of the study was to determine if ED patients who receive nonindicated antibiotic prescriptions for respiratory tract conditions have increased Press Ganey patient satisfaction scores compared with those who do not receive antibiotics. METHODS This was a retrospective observational study. Using an administrative electronic health record data set from 2 EDs in the Midwest, we identified 619 ED encounters resulting in discharge for antibiotic-inappropriate respiratory diagnoses with a corresponding Press Ganey patient satisfaction survey. We compared sociodemographics, encounter variables, and overall Press Ganey patient satisfaction scores between those who did and did not receive antibiotics. We analyzed Press Ganey scores by categorical score distribution and as a dichotomized scale of top box (5) vs other scores. A logistic regression estimated the odds of a top box Press Ganey patient satisfaction score based on antibiotic prescribing while controlling for other covariates. RESULTS In the final sample, 158 (26%) encounters involving antibiotic-inappropriate respiratory diagnoses involved an antibiotic prescription. There were no differences in sociodemographic, encounter or categorical, or top box Press Ganey overall patient satisfaction scores between the groups that did and did not receive inappropriate antibiotics. In the fully adjusted regression model, antibiotic prescriptions were not associated with increased odds of top box Press Ganey patient satisfaction score (odds ratio, 0.78; 95% CI, 0.53-1.14). CONCLUSIONS Our findings suggest that nonindicated antibiotic prescribing for respiratory tract conditions is not a primary driver of overall Press Ganey scores in the ED.
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Affiliation(s)
- Michael S Pulia
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Steven Hesse
- University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Rebecca J Schwei
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | | | - Ajay Sethi
- Department of Population Health, Madison, Wisconsin, USA
| | - Azita Hamedani
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin Madison School of Medicine and Public Health, Madison, Wisconsin, USA
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46
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Wemette M, Safi AG, Beauvais W, Ceres K, Shapiro M, Moroni P, Welcome FL, Ivanek R. New York State dairy farmers' perceptions of antibiotic use and resistance: A qualitative interview study. PLoS One 2020; 15:e0232937. [PMID: 32459799 PMCID: PMC7252592 DOI: 10.1371/journal.pone.0232937] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 04/24/2020] [Indexed: 11/18/2022] Open
Abstract
Antibiotic resistance is a global problem affecting both human and animal health. Ensuring the strategic and effective use of antibiotics is paramount to combatting the emergence and spread of resistance. This study explored New York State (NYS) dairy farmers' perceptions regarding antibiotic use in dairy farming and antibiotic resistance. Dairy farmers' perceptions were assessed through semi-structured, in-person interviews. Twenty interviews with farm owners and/or managers of 15 conventional and five USDA certified organic dairy farms with 40 to 2,300 lactating cows were conducted. Thematic analysis was used to assess, compare and contrast transcripts for farmers' characterization of their beliefs, values, and concerns. Conventional dairy farmers had a low level of concern about the possible impacts of on-farm antibiotic resistance on human health and believed their antibiotic use was already judicious. Generally, they believed their cattle's health would suffer if antibiotic use were further curtailed. Conventional farmers expressed frustration over the possibility of more stringent governmental, milk cooperative, buyer, or marketer requirements for antibiotic use and associated animal welfare in the future. They attributed expanding regulations in part to misinformed consumer preferences, that farmers felt were influenced by the marketing of organic dairy products. Organic dairy farmers were generally more concerned about issues related to antibiotic resistance than conventional farmers. Both conventional and organic farmers placed emphasis on disease prevention through herd health management rather than treatment. In conclusion, the conventional NYS dairy farmers in this study were skeptical of the need for and benefits of reduced antibiotic use on their dairy farms. Interventions for farmers, delivered by a trusted source such as a veterinarian, that provide training about proper antibiotic use practices and information of possible financial benefits of refining antibiotic use may hold promise.
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Affiliation(s)
- Michelle Wemette
- Department of Population Medicine and Diagnostic Sciences, College of Veterinary Medicine, Cornell University, Ithaca, New York, United States of America
| | - Amelia Greiner Safi
- Department of Population Medicine and Diagnostic Sciences, College of Veterinary Medicine, Cornell University, Ithaca, New York, United States of America
- Department of Communication, College of Agriculture and Life Sciences, Cornell University, Ithaca, New York, United States of America
| | - Wendy Beauvais
- Department of Population Medicine and Diagnostic Sciences, College of Veterinary Medicine, Cornell University, Ithaca, New York, United States of America
| | - Kristina Ceres
- Department of Population Medicine and Diagnostic Sciences, College of Veterinary Medicine, Cornell University, Ithaca, New York, United States of America
| | - Michael Shapiro
- Department of Communication, College of Agriculture and Life Sciences, Cornell University, Ithaca, New York, United States of America
| | - Paolo Moroni
- Department of Population Medicine and Diagnostic Sciences, College of Veterinary Medicine, Cornell University, Ithaca, New York, United States of America
- Quality Milk Production Services, Animal Health Diagnostic Center, College of Veterinary Medicine, Cornell University, Ithaca, New York, United States of America
| | - Francis L. Welcome
- Department of Population Medicine and Diagnostic Sciences, College of Veterinary Medicine, Cornell University, Ithaca, New York, United States of America
- Quality Milk Production Services, Animal Health Diagnostic Center, College of Veterinary Medicine, Cornell University, Ithaca, New York, United States of America
| | - Renata Ivanek
- Department of Population Medicine and Diagnostic Sciences, College of Veterinary Medicine, Cornell University, Ithaca, New York, United States of America
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47
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Klatte JM, Knee A, Szczerba F, Horton ER, Kopcza K, Fisher DJ. Identification of High-Yield Targets for Antimicrobial Stewardship Program Efforts Within a Nonfreestanding Children's Hospital. Hosp Pediatr 2020; 9:355-364. [PMID: 31003995 DOI: 10.1542/hpeds.2018-0254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES Identify diagnoses with the highest likelihood of prompting antimicrobial stewardship program (ASP) recommendations and lowest probability of recommendation acceptance, investigate the impact of provider years in practice on recommendation receipt and acceptance, and simultaneously assess the influence of patient and provider-level variables associated with recommendations within a nonfreestanding children's hospital. METHODS Retrospective cohort study of antibiotic courses reviewed by the ASP staff from December 1, 2014 to November 30, 2016. Poisson regression was used to detect associations between diagnoses, provider years in practice, and the probability of recommendation receipt and acceptance. Multivariable logistic regression was used to simultaneously examine the influence of patient and provider-level characteristics on recommendation probability. RESULTS A total of 938 inpatient encounters and 1170 antibiotic courses were included. Diagnoses were associated with provider receipt (P < .001) and acceptance (P < .001) of recommendations, with ear, nose, and throat and/or sinopulmonary diagnoses most likely to prompt recommendations (56%; 95% confidence interval [CI], 48-64) and recommendations for neonatal and/or infant diagnoses accepted least often (67%; 95% CI, 58-76). No associations were initially found between provider experience and recommendation receipt or acceptance, although multivariable analysis revealed a trend between increasing years in practice and recommendation likelihood (P = .001). Vancomycin usage (64%; 95% CI, 56-72) and ear, nose, and throat and/or sinopulmonary diagnoses (56%; 95% CI, 47-65) had the highest probability of a recommendation. Sensitivity analyses revealed that use of diagnosis-related clinical practice guidelines decreased recommendations and increased acceptance rates, especially for the surgery diagnosis category. CONCLUSIONS High-yield targets for ASP activities at our nonfreestanding children's hospital were identified. Clinical practice guidelines have the potential to decrease ASP workload, and their development should be particularly encouraged for ASPs with limited resources.
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Affiliation(s)
- J Michael Klatte
- Department of Pediatrics, Division of Infectious Diseases, .,University of Massachusetts Medical School-Baystate, Springfield, Massachusetts
| | - Alexander Knee
- University of Massachusetts Medical School-Baystate, Springfield, Massachusetts.,Office of Research, Baystate Medical Center, Springfield, Massachusetts.,Department of Medicine, and
| | - Frank Szczerba
- Department of Pharmacy Services, Baystate Health, Springfield, Massachusetts; and
| | - Evan R Horton
- Department of Pharmacy Services, Baystate Health, Springfield, Massachusetts; and.,Massachusetts College of Pharmacy and Health Sciences, Worcester, Massachusetts
| | - Kathleen Kopcza
- Department of Pharmacy Services, Baystate Health, Springfield, Massachusetts; and
| | - Donna J Fisher
- Department of Pediatrics, Division of Infectious Diseases.,University of Massachusetts Medical School-Baystate, Springfield, Massachusetts
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48
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Fanelli U, Chiné V, Pappalardo M, Gismondi P, Esposito S. Improving the Quality of Hospital Antibiotic Use: Impact on Multidrug-Resistant Bacterial Infections in Children. Front Pharmacol 2020; 11:745. [PMID: 32499712 PMCID: PMC7243475 DOI: 10.3389/fphar.2020.00745] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 05/04/2020] [Indexed: 12/20/2022] Open
Abstract
Antimicrobial resistance (AMR) is considered a rapidly growing global public health emergency. Neonates and children are among patients for whom antibiotics are largely prescribed and for whom the risk of AMR development is high. The phenomenon of increasing AMR has led to the need to develop measures aimed at the rational and effective use of the available drugs also in children and antimicrobial stewardship (AS), which is one of the measures that in adults has showed the highest efficacy in reducing antibiotic abuse and misuse, appears as an attractive approach. The aim of this manuscript is to analyze the basic principles and strategies of pediatric AS. To this end, we searched in PubMed articles published in years 2000 to 2019 containing "antimicrobial resistance," "antibiotic use," "antimicrobial stewardship," and "children" or "pediatric" as keywords. Our review showed that the balance between multi-resistant organisms and new antimicrobials is extremely precarious. The AS tools are the most important weapon at our disposal to stem the phenomenon. Careful monitoring of prescriptions, continuous training of prescribing physicians and collaboration with highly qualified multidisciplinary staff, creation of local and national guidelines, use of rapid diagnostic tests, technological means of support, and research activities by testing new broad-spectrum antibiotics are mandatory. However, all of these measures must be supported by adequate investment by national and international health organizations. Only by making AS daily practice, through the use of financial resources and dedicated staff, we can fight AMR to ensure safe and effective care for our young patients.
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Affiliation(s)
| | | | | | | | - Susanna Esposito
- Department of Medicine and Surgery, Pediatric Clinic, Pietro Barilla Children's Hospital, University of Parma, Parma, Italy
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Jeffs L, McIsaac W, Zahradnik M, Senthinathan A, Dresser L, McIntyre M, Tannenbaum D, Bell C, Morris A. Barriers and facilitators to the uptake of an antimicrobial stewardship program in primary care: A qualitative study. PLoS One 2020; 15:e0223822. [PMID: 32134929 PMCID: PMC7059986 DOI: 10.1371/journal.pone.0223822] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Accepted: 09/30/2019] [Indexed: 01/21/2023] Open
Abstract
The overuse of antimicrobials in primary care can be linked to an increased risk of antimicrobial-resistant bacteria for individual patients. Although there are promising signs of the benefits associated with Antimicrobial Stewardship Programs (ASPs) in hospitals and long-term care settings, there is limited knowledge in primary care settings and how to implement ASPs in these settings is unclear. In this context, a qualitative study was undertaken to explore the perceptions of primary care prescribers of the usefulness, feasibility, and experiences associated with the implementation of a pilot community-focused ASP intervention in three primary care clinics. Qualitative interviews were conducted with primary care clinicians, including local ASP champions, prescribers, and other primary health care team members, while they participated in an ASP initiative within one of three primary care clinics. An iterative conventional content analyses approach was used to analyze the transcribed interviews. Themes emerged around the key enablers and barriers associated with ASP implementation. Study findings point to key insights relevant to the scalability of community ASP activities with primary care providers.
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Affiliation(s)
- Lianne Jeffs
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto,
Ontario, Canada
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michaels
Hospital, Toronto, Ontario, Canada
| | - Warren McIsaac
- Ray D. Wolfe Department of Family and Community Medicine, Sinai Health
System, Toronto Canada
- Department of Family and Community Medicine, University of Toronto,
Toronto, Canada
| | | | - Arrani Senthinathan
- Antimicrobial Stewardship Program, Sinai Health System and University
Health Network, Toronto, Canada
| | - Linda Dresser
- Antimicrobial Stewardship Program, Sinai Health System and University
Health Network, Toronto, Canada
| | - Mark McIntyre
- Antimicrobial Stewardship Program, Sinai Health System and University
Health Network, Toronto, Canada
| | - David Tannenbaum
- Ray D. Wolfe Department of Family and Community Medicine, Sinai Health
System, Toronto Canada
- Department of Family and Community Medicine, University of Toronto,
Toronto, Canada
| | - Chaim Bell
- Antimicrobial Stewardship Program, Sinai Health System and University
Health Network, Toronto, Canada
- Department of Medicine, Sinai Health System, University Health Network,
and University of Toronto, Toronto, Canada
| | - Andrew Morris
- Antimicrobial Stewardship Program, Sinai Health System and University
Health Network, Toronto, Canada
- Department of Medicine, Sinai Health System, University Health Network,
and University of Toronto, Toronto, Canada
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50
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Rational use of antimicrobials in the treatment of upper airway infections. J Pediatr (Rio J) 2020; 96 Suppl 1:111-119. [PMID: 31857096 PMCID: PMC9432007 DOI: 10.1016/j.jped.2019.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 11/07/2019] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE To analyze the main cause of the irresponsible use of antibiotics at the pediatric level in a very frequent, usually self-limited, and typically viral condition: upper airway respiratory infections. SOURCES Different databases were searched using specific terms related to resistance to antibiotics, upper airway respiratory infections, and pediatrics patients. SUMMARY OF THE FINDINGS Effectiveness varies depending on the place, the form of intervention, and the resources used. Multiple interventions appear to be more effective. The foundations of treatment are training in technical aspects and in communication skills for the prescribers, and having enough time for each patient; and training through the health clinic and the media for patients/parents. Deferred prescription and the use of rapid diagnostic tests in the primary care setting have been shown to be effective. A fluid relationship based on trust between clinicians and parents/guardians is one of the keystones. CONCLUSIONS Any project that seeks to be totally effective must include a health authority, which in addition to helping implement these measures, has the firm intention of drastically reducing the use of antibiotics in animals and in the environment, as well as favoring research into new antimicrobials.
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