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Lo Moro G, Marengo N, Mara A, Paño Pardo JR, Hernandez S, Fusté E, Pujol M, Zotti CM, Limón E, Vicentini C. Antimicrobial stewardship programs in acute-care hospitals: A multicenter assessment of structure, process, and outcome indicators in Italy and Spain. J Infect Public Health 2024; 17:102457. [PMID: 38820893 DOI: 10.1016/j.jiph.2024.05.045] [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: 10/28/2023] [Revised: 05/03/2024] [Accepted: 05/21/2024] [Indexed: 06/02/2024] Open
Abstract
BACKGROUND Antimicrobial stewardship (AMS) programs have been differently implemented across Europe. This study primarily aimed to compare AMS in two European regions. Secondarily, the study explored the COVID-19 pandemic impact on surrogate outcome indicators of AMS. METHODS A retrospective observational study was conducted in Piedmont (Italy) and Catalonia (Spain). AMS programs were compared through structure and process indicators in 2021. Changes in surrogate outcome indicators (antimicrobial usage; alcohol-based sanitizer consumption; antimicrobial resistance, AMR) from 2017 to 2021 described the pandemic impact. RESULTS Seventy-eight facilities provided structure and process indicators. Catalonia showed better structure scores (p < 0.001) and less dispersion in both indicators. The greatest areas to improve were accountability (Piedmont) and diversification of strategies (Catalonia). Overall, the regions reported consistent changes in outcome indicators. Antimicrobial usage decreased in 2020, returning to near-pre-pandemic levels in 2021. Alcohol-based sanitizer consumption surged in 2020, then dipped remaining above pre-pandemic levels. AMR trends were minimally affected. CONCLUSIONS The centralized approach of Catalonia ensured consistent attainment of quality objectives across all facilities, but it may limit facility-specific strategies. In Piedmont, accountability remain one of the most critical factors as in previous years. The pandemic did not substantially disrupt surrogate outcome measures of AMS. However, the data on AMR suggest that maintaining vigilance against this issue remains paramount.
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Affiliation(s)
- Giuseppina Lo Moro
- Department of Public Health and Pediatrics, University of Turin, Turin, Italy.
| | - Noemi Marengo
- Department of Public Health and Pediatrics, University of Turin, Turin, Italy
| | - Alessandro Mara
- Department of Public Health and Pediatrics, University of Turin, Turin, Italy
| | - José Ramón Paño Pardo
- Fundación Instituto de Investigación Sanitaria Aragón (IIS Aragón), Biomedical Research Centre of Aragón (CIBA), Zaragoza, Spain; Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - Sergi Hernandez
- Centro Coordinador Programa VINCat, Institut Català d'Oncologia, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Ester Fusté
- Department of Public Health, Mental Health and Maternal and Child Health Nursing, Faculty of Nursing. University of Barcelona, Spain; Department of Pathology and Experimental Therapeutics, University of Barcelona and IDIBELL, Faculty of Medicine and Health Sciences University of Barcelona, L'Hospitalet de Llobregat, Spain
| | - Miquel Pujol
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain; VINCat Program, Servei Català de la Salut, Barcelona, Spain
| | - Carla Maria Zotti
- Department of Public Health and Pediatrics, University of Turin, Turin, Italy
| | - Enric Limón
- Centro Coordinador Programa VINCat, Institut Català d'Oncologia, L'Hospitalet de Llobregat, Barcelona, Spain; Department of Public Health, Mental Health and Maternal and Child Health Nursing, Faculty of Nursing. University of Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Costanza Vicentini
- Department of Public Health and Pediatrics, University of Turin, Turin, Italy
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2
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Xia H, Li J, Yang X, Zeng Y, Shi L, Li W, Liu X, Yang S, Zhao M, Chen J, Yang L. Effects of pay-for-performance based antimicrobial stewardship on antimicrobial consumption and expenditure: An interrupted time series analysis. Heliyon 2024; 10:e32750. [PMID: 38975216 PMCID: PMC11226823 DOI: 10.1016/j.heliyon.2024.e32750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 06/04/2024] [Accepted: 06/07/2024] [Indexed: 07/09/2024] Open
Abstract
Objectives To evaluate the impact of pay-for-performance on antimicrobial consumption and antimicrobial expenditure in a large teaching hospital in Guangzhou, China. Methods We collected data from hospital information system from January 2018 through September 2022 in the inpatient wards. Antimicrobial consumption was evaluated using antibiotic use density (AUD) and antibiotic use rate (AUR). The economic impact of intervention was assessed by antimicrobial expenditure percentage. The data was analyzed using interrupted time series (ITS) analysis. Results Following the implementation of the intervention, immediate decreases in the level of AUD were observed in Department of Hematology Unit 3 (β = -66.93 DDDs/100PD, P = 0.002), Urology (β = -32.80 DDDs/100PD, P < 0.001), Gastrointestinal Surgery Unit 3 (β = -11.44 DDDs/100PD, P = 0.03), Cardiac Surgery (β = -14.30 DDDs/100PD, P = 0.01), ICU, Unit 2 (β = -81.91 DDDs/100PD, P = 0.02) and Cardiothoracic Surgery ICU (β = -41.52 DDDs/100PD, P = 0.05). Long-term downward trends in AUD were also identified in Organ Transplant Unit (β = -1.64 DDDs/100PD, P = 0.02). However, only Urology (β = -6.56 DDDs/100PD, P = 0.02) and Gastrointestinal Surgery Unit 3 (β = -8.50 %, P = 0.01) showed an immediate decrease in AUR, and long-term downward trends in AUR were observed in Pediatric ICU (β = -1.88 %, P = 0.05) and ICU Unit 1 (β = -0.55 %, P = 0.02). Conclusion This study demonstrates that the adoption of pay-for-performance effectively reduces antibiotic consumption in specific departments of a hospital in Guangzhou in the short term. However, it is important to recognize that the long-term impact of such interventions is often limited. Additionally, it should be noted that the overall effectiveness of the intervention across the entire hospital was not significant.
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Affiliation(s)
- Haohai Xia
- School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Jia Li
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xinyi Yang
- School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Yingchao Zeng
- School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Lin Shi
- School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Weibin Li
- School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Xu Liu
- Department of Infectious Disease, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, China
| | - Shifang Yang
- Department of Pulmonary and Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Southern Medical University, Guangzhou, China
| | - Manzhi Zhao
- Department of Pulmonary and Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Southern Medical University, Guangzhou, China
| | - Jie Chen
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Lianping Yang
- School of Public Health, Sun Yat-sen University, Guangzhou, China
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3
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Knowles R, Chandler C, O’Neill S, Sharland M, Mays N. A systematic review of national interventions and policies to optimize antibiotic use in healthcare settings in England. J Antimicrob Chemother 2024; 79:1234-1247. [PMID: 38507232 PMCID: PMC11144483 DOI: 10.1093/jac/dkae061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 02/19/2024] [Indexed: 03/22/2024] Open
Abstract
OBJECTIVES To identify and assess the effectiveness of national antibiotic optimization interventions in primary and secondary care in England (2013-2022). METHODS A systematic scoping review was conducted. Literature databases (Embase and Medline) were used to identify interventions and evaluations. Reports included the UK AMR Strategy (2013-2018), National Action Plan (2019-2024) and English Surveillance Programme for Antimicrobial Utilisation and Resistance (ESPAUR) reports (2014-2022). The design, focus and quality of evaluations and the interventions' effectiveness were extracted. FINDINGS Four hundred and seventy-seven peer-reviewed studies and 13 reports were screened. One hundred and three studies were included for review, identifying 109 interventions in eight categories: policy and commissioning (n = 9); classifications (n = 1); guidance and toolkits (n = 22); monitoring and feedback (n = 17); professional engagement and training (n = 19); prescriber tools (n = 12); public awareness (n = 17); workforce and governance (n = 12).Most interventions lack high-quality effectiveness evidence. Evaluations mainly focused on clinical, microbiological or antibiotic use outcomes, or intervention implementation, often assessing how interventions were perceived to affect behaviour. Only 16 interventions had studies that quantified effects on prescribing, of which six reported reductions. The largest reduction was reported with structural-level interventions and attributed to a policy and commissioning intervention (primary care financial incentives). Behavioural interventions (guidance and toolkits) reported the greatest impact in hospitals. CONCLUSIONS Many interventions have targeted antibiotic use, each pulling different levers across the health system simultaneously. On the basis of these studies, structural-level interventions may have the greatest impact. Collectively, the combination of interventions may explain England's decline in prescribing but direct evidence of causality is unavailable.
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Affiliation(s)
- Rebecca Knowles
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Clare Chandler
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Stephen O’Neill
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Mike Sharland
- Centre for Neonatal and Paediatric Infection, Institute for Infection and Immunity, St George’s, University of London, London, UK
- Paediatric Infectious Diseases Department, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Nicholas Mays
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Sanchez GV, Kabbani S, Tsay SV, Bizune D, Hersh AL, Luciano A, Hicks LA. Antibiotic Stewardship in Outpatient Telemedicine: Adapting Centers for Disease Control and Prevention Core Elements to Optimize Antibiotic Use. Telemed J E Health 2024; 30:951-962. [PMID: 37856146 DOI: 10.1089/tmj.2023.0229] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2023] Open
Abstract
The rapid expansion of telemedicine has highlighted challenges and opportunities to improve antibiotic use and effectively adapt antibiotic stewardship best practices to outpatient telemedicine settings. Antibiotic stewardship integration into telemedicine is essential to optimize antibiotic prescribing for patients and ensure health care quality. We performed a narrative review of published literature on antibiotic prescribing and stewardship in outpatient telemedicine to inform the adaptation of the Core Elements of Outpatient Antibiotic Stewardship framework to outpatient telemedicine settings. Our narrative review suggests that in-person antibiotic stewardship interventions can be adapted to outpatient telemedicine settings. We present considerations for applying the Core Elements of Outpatient Antibiotic Stewardship to outpatient telemedicine which builds upon growing evidence describing care delivery and quality improvement in this setting. Additional applied implementation research is necessary to inform the application of effective, sustainable, and equitable antibiotic stewardship interventions across the spectrum of outpatient telemedicine.
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Affiliation(s)
- Guillermo V Sanchez
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Sarah Kabbani
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Sharon V Tsay
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Destani Bizune
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Adam L Hersh
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Angelina Luciano
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Lauri A Hicks
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Charbonneau M, Morgan SG, Gagnon C, Sadowski CA, Silvius JL, Tannenbaum C, Turner JP. Factors influencing the effects of policies and interventions to promote the appropriate use of medicines in high-income countries: A rapid realist review. Health Policy 2024; 142:105027. [PMID: 38452575 DOI: 10.1016/j.healthpol.2024.105027] [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: 02/06/2023] [Revised: 11/28/2023] [Accepted: 02/17/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND The appropriate use of medicines has long been recognized as a fundamental component of medicine policies. We aimed to extract lessons from published research on how policy contexts and mechanisms can affect the outcomes of national- or health-system level interventions to promote appropriate medicine use (defined as an increase in underutilized medications or decrease in inappropriate medication use). METHODS We conducted a rapid realist review of published evidence concerning system-level policies to promote the appropriate use of medicines in high-income countries with universal prescription drug coverage. We searched MEDLINE and Embase to identify relevant publications. We used a realist evaluation framework to identify contexts, mechanisms, and outcomes for each intervention and to hypothesize which policy contexts and mechanisms supported successful outcomes in terms of relative changes in the prevalence of use of the specific medication classes targeted. RESULTS From 1,318 identified studies, 18 met our inclusion criteria. 13 distinct policies were identified. Three main policy-related factors underpinned successful interventions: involving providers and patients through program interventions; central coordination through national agencies dedicated to medicine policies; and the establishment of an explicit and integrated national medicine policy strategy. CONCLUSION Policymakers can improve coordination of national pharmaceutical policies to reduce harms from inappropriate medicines use, thus improving health outcomes through cost-effective programs.
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Affiliation(s)
- Mathieu Charbonneau
- Canadian Medication Appropriateness and Deprescribing Network, Montreal, Université de Montréal, QC, Canada.
| | - Steven G Morgan
- School of Population and Public Health, University of British Columbia, Vancouver BC, Canada
| | - Camille Gagnon
- Canadian Medication Appropriateness and Deprescribing Network, Université de Montréal, Montreal, QC, Canada
| | - Cheryl A Sadowski
- Faculty of Pharmacy & Pharmaceutical Sciences, University of Alberta, Edmonton, AB, Canada
| | - James L Silvius
- Alberta Health Services, Edmonton, AB, Canada; Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Cara Tannenbaum
- Faculties of Pharmacy and Medicine, Université de Montréal, Montreal, QC, Canada; Michel Saucier Endowed Chair in Pharmacy, Health & Aging, Université de Montréal, Montreal, QC, Canada
| | - Justin P Turner
- Faculté de Pharmacie, Université de Montréal, Montreal, QC, Canada; Centre de Recherche de l'Institut Universitaire de Gériatrie de Montréal, Montreal, QC, Canada; Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia
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6
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Zhong X, Pate A, Yang YT, Fahmi A, Ashcroft DM, Goldacre B, MacKenna B, Mehrkar A, Bacon SCJ, Massey J, Fisher L, Inglesby P, Hand K, van Staa T, Palin V. Impact of COVID-19 on broad-spectrum antibiotic prescribing for common infections in primary care in England: a time-series analyses using OpenSAFELY and effects of predictors including deprivation. THE LANCET REGIONAL HEALTH. EUROPE 2023; 30:100653. [PMID: 37363797 PMCID: PMC10186397 DOI: 10.1016/j.lanepe.2023.100653] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 04/25/2023] [Accepted: 04/28/2023] [Indexed: 06/28/2023]
Abstract
Background The COVID-19 pandemic impacted the healthcare systems, adding extra pressure to reduce antimicrobial resistance. Therefore, we aimed to evaluate changes in antibiotic prescription patterns after COVID-19 started. Methods With the approval of NHS England, we used the OpenSAFELY platform to access the TPP SystmOne electronic health record (EHR) system in primary care and selected patients prescribed antibiotics from 2019 to 2021. To evaluate the impact of COVID-19 on broad-spectrum antibiotic prescribing, we evaluated prescribing rates and its predictors and used interrupted time series analysis by fitting binomial logistic regression models. Findings Over 32 million antibiotic prescriptions were extracted over the study period; 8.7% were broad-spectrum. The study showed increases in broad-spectrum antibiotic prescribing (odds ratio [OR] 1.37; 95% confidence interval [CI] 1.36-1.38) as an immediate impact of the pandemic, followed by a gradual recovery with a 1.1-1.2% decrease in odds of broad-spectrum prescription per month. The same pattern was found within subgroups defined by age, sex, region, ethnicity, and socioeconomic deprivation quintiles. More deprived patients were more likely to receive broad-spectrum antibiotics, which differences remained stable over time. The most significant increase in broad-spectrum prescribing was observed for lower respiratory tract infection (OR 2.33; 95% CI 2.1-2.50) and otitis media (OR 1.96; 95% CI 1.80-2.13). Interpretation An immediate reduction in antibiotic prescribing and an increase in the proportion of broad-spectrum antibiotic prescribing in primary care was observed. The trends recovered to pre-pandemic levels, but the consequence of the COVID-19 pandemic on AMR needs further investigation. Funding This work was supported by Health Data Research UK and by National Institute for Health Research.
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Affiliation(s)
- Xiaomin Zhong
- Centre for Health Informatics, School of Health Sciences, Faculty of Biology, Medicine, and Health, the University of Manchester, M13 9PL, UK
| | - Alexander Pate
- Centre for Health Informatics, School of Health Sciences, Faculty of Biology, Medicine, and Health, the University of Manchester, M13 9PL, UK
| | - Ya-Ting Yang
- Centre for Health Informatics, School of Health Sciences, Faculty of Biology, Medicine, and Health, the University of Manchester, M13 9PL, UK
| | - Ali Fahmi
- Centre for Health Informatics, School of Health Sciences, Faculty of Biology, Medicine, and Health, the University of Manchester, M13 9PL, UK
| | - Darren M. Ashcroft
- Centre for Pharmacoepidemiology and Drug Safety, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Oxford Road, Manchester, M13 9PL, UK
- NIHR Greater Manchester Patient Safety Translational Research Centre, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Oxford Road, Manchester, M13 9PL, UK
| | - Ben Goldacre
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX2 6GG, UK
| | - Brian MacKenna
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX2 6GG, UK
- NHS England, Wellington House, Waterloo Road, London, SE1 8UG, UK
| | - Amir Mehrkar
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX2 6GG, UK
| | - Sebastian CJ. Bacon
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX2 6GG, UK
| | - Jon Massey
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX2 6GG, UK
| | - Louis Fisher
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX2 6GG, UK
| | - Peter Inglesby
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX2 6GG, UK
| | - the OpenSAFELY collaborative
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX2 6GG, UK
| | - Kieran Hand
- Pharmacy Department, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
- NHS England, Wellington House, Waterloo Road, London, SE1 8UG, UK
| | - Tjeerd van Staa
- Centre for Health Informatics, School of Health Sciences, Faculty of Biology, Medicine, and Health, the University of Manchester, M13 9PL, UK
| | - Victoria Palin
- Centre for Health Informatics, School of Health Sciences, Faculty of Biology, Medicine, and Health, the University of Manchester, M13 9PL, UK
- Maternal and Fetal Research Centre, Division of Developmental Biology and Medicine, the University of Manchester, St Marys Hospital, Oxford Road, Manchester, M13 9WL, UK
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Stenehjem E, Wallin A, Willis P, Kumar N, Seibert AM, Buckel WR, Stanfield V, Brunisholz KD, Fino N, Samore MH, Srivastava R, Hicks LA, Hersh AL. Implementation of an Antibiotic Stewardship Initiative in a Large Urgent Care Network. JAMA Netw Open 2023; 6:e2313011. [PMID: 37166794 PMCID: PMC10176123 DOI: 10.1001/jamanetworkopen.2023.13011] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 03/19/2023] [Indexed: 05/12/2023] Open
Abstract
Importance Urgent Care (UC) encounters result in more inappropriate antibiotic prescriptions than other outpatient setting. Few stewardship interventions have focused on UC. Objective To evaluate the effectiveness of an antibiotic stewardship initiative to reduce antibiotic prescribing for respiratory conditions in a UC network. Design, Setting, and Participants This quality improvement study conducted in a UC network with 38 UC clinics and 1 telemedicine clinic included 493 724 total UC encounters. The study compared the antibiotic prescribing rates of all UC clinicians who encountered respiratory conditions for a 12-month baseline period (July 1, 2018, through June 30, 2019) with an intervention period (July 1, 2019, through June 30, 2020). A sustainability period (July 1, 2020, through June 30, 2021) was added post hoc. Interventions Stewardship interventions included (1) education for clinicians and patients, (2) electronic health record (EHR) tools, (3) a transparent clinician benchmarking dashboard, and (4) media. Occurring independently but concurrent with the interventions, a stewardship measure was introduced by UC leadership into the quality measures, including a financial incentive. Main Outcomes and Measures The primary outcome was the percentage of UC encounters with an antibiotic prescription for a respiratory condition. Secondary outcomes included antibiotic prescribing when antibiotics were not indicated (tier 3 encounters) and first-line antibiotics for acute otitis media, sinusitis, and pharyngitis. Interrupted time series with binomial generalized estimating equations were used to compare periods. Results The baseline period included 207 047 UC encounters for respiratory conditions (56.8% female; mean [SD] age, 30.0 [21.4] years; 92.0% White race); the intervention period included 183 893 UC encounters (56.4% female; mean [SD] age, 30.7 [20.8] years; 91.2% White race). Antibiotic prescribing for respiratory conditions decreased from 47.8% (baseline) to 33.3% (intervention). During the initial intervention month, a 22% reduction in antibiotic prescribing occurred (odds ratio [OR], 0.78; 95% CI, 0.71-0.86). Antibiotic prescriptions decreased by 5% monthly during the intervention (OR, 0.95; 95% CI, 0.94-0.96). Antibiotic prescribing for tier 3 encounters decreased by 47% (OR, 0.53; 95% CI, 0.44-63), and first-line antibiotic prescriptions increased by 18% (OR, 1.18; 95% CI, 1.09-1.29) during the initial intervention month. Antibiotic prescriptions for tier 3 encounters decreased by an additional 4% each month (OR, 0.96; 95% CI, 0.94-0.98), whereas first-line antibiotic prescriptions did not change (OR, 1.00; 95% CI, 0.99-1.01). Antibiotic prescribing for respiratory conditions remained stable in the sustainability period. Conclusions and relevance The findings of this quality improvement study indicated that a UC antibiotic stewardship initiative was associated with decreased antibiotic prescribing for respiratory conditions. This study provides a model for UC antibiotic stewardship.
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Affiliation(s)
- Edward Stenehjem
- Division of Infectious Diseases and Epidemiology, Intermountain Health, Salt Lake City, Utah
| | - Anthony Wallin
- Intermountain Urgent Care, Intermountain Health, Salt Lake City, Utah
| | - Park Willis
- Intermountain Urgent Care, Intermountain Health, Salt Lake City, Utah
| | - Naresh Kumar
- Office of Research, Intermountain Health, Salt Lake City, Utah
| | - Allan M. Seibert
- Division of Infectious Diseases and Epidemiology, Intermountain Health, Salt Lake City, Utah
| | - Whitney R. Buckel
- System Pharmacy Services, Intermountain Health, Salt Lake City, Utah
| | - Valoree Stanfield
- Division of Infectious Diseases and Epidemiology, Intermountain Health, Salt Lake City, Utah
| | | | - Nora Fino
- Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, Salt Lake City
| | - Matthew H. Samore
- Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, Salt Lake City
| | - Rajendu Srivastava
- Intermountain Health Delivery Institute, Intermountain Health, Salt Lake City, Utah
- Department of Pediatrics, Division of Pediatric Inpatient Medicine, University of Utah School of Medicine, Salt Lake City
| | - Lauri A. Hicks
- Office of Antibiotic Stewardship, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Adam L. Hersh
- Department of Pediatrics, Division of Infectious Diseases, University of Utah School of Medicine, Salt Lake City
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8
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Drwiega EN, Griffith N, Herald F, Badowski ME. How to design and implement an outpatient antimicrobial stewardship programme. Drugs Context 2023; 12:dic-2022-8-2. [PMID: 36843620 PMCID: PMC9949762 DOI: 10.7573/dic.2022-8-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 01/12/2023] [Indexed: 02/17/2023] Open
Abstract
Antimicrobial stewardship programmes in the outpatient setting have recently become an area of focus in an effort to improve antimicrobial prescribing. The Centers for Disease Control and Prevention and The Joint Commission have recently addressed this concern and provided a framework for the implementation of an outpatient stewardship programme. This manuscript offers detailed guidance on how to design and implement an outpatient antimicrobial stewardship programme and reviews the literature on current strategies. Challenges related to initiating and maintaining outpatient stewardship efforts are also discussed. This article is part of the Antibiotic stewardship Special Issue: https://www.drugsincontext.com/special_issues/antimicrobial-stewardship-a-focus-on-the-need-for-moderation.
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Affiliation(s)
- Emily N Drwiega
- University of Illinois at Chicago, College of Pharmacy, Chicago, IL, USA
| | - Nicole Griffith
- University of Illinois at Chicago, College of Pharmacy, Chicago, IL, USA
| | - Fischer Herald
- University of Illinois at Chicago, College of Pharmacy, Chicago, IL, USA
| | - Melissa E Badowski
- University of Illinois at Chicago, College of Pharmacy, Chicago, IL, USA
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9
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Decline in oral antimicrobial prescription in the outpatient setting after nationwide implementation of financial incentives and provider education: An interrupted time-series analysis. Infect Control Hosp Epidemiol 2023; 44:253-259. [PMID: 35382915 DOI: 10.1017/ice.2022.49] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES To assess the impact of nationwide outpatient antimicrobial stewardship interventions in the form of financial incentives for providers and provider education when antimicrobials are deemed unnecessary for uncomplicated respiratory infections and acute diarrhea. METHODS We collected data from a large claims database from April 2013 through March 2020 and performed a quasi-experimental, interrupted time-series analysis. The outcome of interest was oral antimicrobial prescription rate defined as the number of monthly antimicrobial prescriptions divided by the number of outpatient visits each month. We examined the effects of financial incentive to providers (ie, targeted prescriptions for those aged ≤2 years) and provider education (ie, targeted prescriptions for those aged ≥6 years) on the overall antimicrobial prescription rates and how these interventions affected different age groups before and after their implementation. RESULTS In total, 21,647,080 oral antimicrobials were prescribed to 2,920,381 unique outpatients during the study period. At baseline, prescription rates for all age groups followed a downward trend throughout the study period. Immediately after the financial incentive implementation, substantial reductions in prescription rates were observed among only those aged 0-2 years (-47.5 prescriptions per 1,000 clinic visits each month; 95% confidence interval, -77.3 to -17.6; P = .003), whereas provider education immediately reduced prescription rates in all age groups uniformly. These interventions did not affect the long-term trend for any age group. CONCLUSION These results suggest that the nationwide implementation of financial incentives and provider education had an immediate effect on the antimicrobial prescription but no long-term effect.
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10
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Roche KF, Morrissey EC, Cunningham J, Molloy GJ. The use of postal audit and feedback among Irish General Practitioners for the self – management of antimicrobial prescribing: a qualitative study. BMC PRIMARY CARE 2022; 23:86. [PMID: 35436863 PMCID: PMC9014781 DOI: 10.1186/s12875-022-01695-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 04/07/2022] [Indexed: 11/23/2022]
Abstract
Objective Inappropriate use of antibiotics has been acknowledged as a significant contributor to the proliferation of antimicrobial resistance worldwide. Physician prescribing of antibiotics has been identified as a factor in the inappropriate use of antibiotics. One methodology that is used in an attempt to alter physician prescribing behaviours is audit and feedback. This study aimed to explore the perceptions of Irish General Practitioners (GPs) towards the national introduction of postal feedback on their antibiotic prescribing behaviours beginning in 2019. Design A qualitative descriptive methodology was used. Semi–structured interviews were conducted with GPs in receipt of postal audit and feedback. Method GPs working in Ireland and in receipt of postal audit and feedback on their antibiotic prescribing behaviours participated in phone-based interviews. The interviews were recorded and transcribed verbatim. The collected data was then analysed using an inductive thematic analysis. Results Twelve GPs participated in the study (female = 5). Three themes were identified from the analysis. The themes identified were the reliability and validity of the feedback received, feedback on antibiotic prescribing is useful but limited and feedback needs to be easily digestible. Conclusion While the postal audit and feedback were broadly welcomed by the participants, the themes identified a perceived limitation in the quality of the feedback data, the perception of a likely low public health impact of the feedback and difficulties with efficiently processing the audit and feedback information. These findings can help refine future audit and feedback interventions on antibiotic prescribing. Supplementary Information The online version contains supplementary material available at 10.1186/s12875-022-01695-x.
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Application Effect of Transparent Supervision Based on Informatization in Prevention and Control of Carbapenem-Resistant Klebsiella pneumoniae Nosocomial Infection. THE CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY = JOURNAL CANADIEN DES MALADIES INFECTIEUSES ET DE LA MICROBIOLOGIE MEDICALE 2022; 2022:2193430. [PMID: 36329985 PMCID: PMC9626236 DOI: 10.1155/2022/2193430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 08/04/2022] [Accepted: 10/17/2022] [Indexed: 11/06/2022]
Abstract
Objective To explore the effect of transparent supervision model on the prevention and control of carbapenem-resistant Klebsiella pneumoniae (CRKP) nosocomial infection and the value of the autoregressive integrated moving average (ARIMA) model in predicting the incidence of CRKP infection. Methods A total of 46,873 inpatients from Jiawang District People's Hospital of Xuzhou between January 2019 and December 2019 (prior to COVID-19 prevention and control) were selected as the preintervention group and 45,217 inpatients from January 2020 to December 2020 (after the COVID-19 prevention and control) as the postintervention group. We performed transparent supervision on CRKP patients detected by the real-time monitoring system for nosocomial infection. Incidence and detection rate of CRKP, utilization rate of special grade hydrocarbon enzyme alkene antibiotics, hand hygiene compliance rate, qualified rate of ATP tests on surface of environmental objects, and execution rate of CRKP core prevention and control were compared between the two groups. Results Transparent supervision of CRKP-infected patients was conducted daily from January to December 2020, which resulted in the following: (a) the infection rate of CRKP decreased in a fluctuating manner, and the actual value of hydrocarbon alkene use rate was basically the same as the predicted value with an overall decreasing trend; (b) after the intervention, hand hygiene compliance rate increased from 53.30% to 70.24% (P < 0.001) and the ATP qualified rate increased from 53.77% to 92.24% (P < 0.001); (c) the fitted value of the ARIMA model was in good agreement with the actual value. The incidence of CRKP infection and the utilization rate of carbene antibiotics were also in good agreement with the predicted value. The average relative errors were 11% and 10.78%. Conclusions During the COVID-19 outbreak in 2020, the ARIMA model effectively fit and predicted the CRKP infection rate, thereby providing scientific guidance for the prevention and control of CRKP infection. In addition, the transparent supervision intervention model improved the hand hygiene compliance and environmental hygiene qualification rates of medical staff, effectively reducing CRKP cross-infection in the hospital.
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Effectiveness of Antimicrobial Stewardship Program in Long-Term Care: A Five-Year Prospective Single-Center Study. Interdiscip Perspect Infect Dis 2022; 2022:8140429. [PMID: 35464254 PMCID: PMC9019452 DOI: 10.1155/2022/8140429] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 03/15/2022] [Indexed: 11/18/2022] Open
Abstract
Objective To report the effectiveness of the antimicrobial stewardship program (ASP) in a long-term care (LTC) facility, by analyzing the change in antimicrobial consumption and cost and multidrug resistance (MDR) rates over a 5-year period. Method A prospective interventional study was conducted at a 106-bed facility (nursing home: 100 beds and an intensive care unit (ICU): 6 beds). The ASP was designed and led by a multidisciplinary team including an infectious disease consultant, two clinical pharmacists, a clinical microbiologist, and an infection control preventionist. Five key performance indicators were monitored: (1) intravenous (IV)-to-oral switch rate, (2) consumption of restricted IV antimicrobials (raw consumption and defined daily doses (DDD) index), (3) cost of restricted IV antimicrobials, (4) antimicrobial sensitivity profiles, and (5) MDR rate among hospital-acquired infections (MDR-HAI). Result A ∼5.5-fold enhancement of the IV-to-oral switch and a 40% reduction in the overall consumption of restricted IV antimicrobials were observed. Regarding the cost, the cumulative cost saving was estimated as 5.64 million SAR (US$1.50 million). Microbiologically, no significant change in antimicrobial sensitivity profiles was observed; however, a large-size reduction in the MDR-HAI rate was observed, notably in ICU where it declined from 3.22 per 1,000 patient days, in 2015, to 1.14 per 1,000 patient days in 2020. Interestingly, the yearly overall MDR rate was strongly correlated with the level of antimicrobial consumption. Conclusion The implementation of a multidisciplinary ASP in LTC facilities should be further encouraged, with emphasis on physicians' education and active involvement to enhance the success of the strategy.
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Hawkins O, Scott AM, Montgomery A, Nicholas B, Mullan J, van Oijen A, Degeling C. Comparing public attitudes, knowledge, beliefs and behaviours towards antibiotics and antimicrobial resistance in Australia, United Kingdom, and Sweden (2010-2021): A systematic review, meta-analysis, and comparative policy analysis. PLoS One 2022; 17:e0261917. [PMID: 35030191 PMCID: PMC8759643 DOI: 10.1371/journal.pone.0261917] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 12/13/2021] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Social and behavioural drivers of inappropriate antibiotic use contribute to antimicrobial resistance (AMR). Recent reports indicate the Australian community consumes more than twice the defined daily doses (DDD) of antibiotics per 1000 population than in Sweden, and about 20% more than in the United Kingdom (UK). We compare measures of public knowledge, attitudes and practices (KAP) surrounding AMR in Australia, the UK and Sweden against the policy approaches taken in these settings to address inappropriate antibiotic use. METHODS National antimicrobial stewardship policies in Australia, Sweden, and the UK were reviewed, supplemented by empirical studies of their effectiveness. We searched PubMed, EMBASE, PsycINFO, Web of Science and CINAHL databases for primary studies of the general public's KAP around antibiotic use and AMR in each setting (January 1 2011 until July 30 2021). Where feasible, we meta-analysed data on the proportion of participants agreeing with identical or very similar survey questions, using a random effects model. RESULTS Policies in Sweden enact tighter control of community antibiotic use; reducing antibiotic use through public awareness raising is not a priority. Policies in the UK and Australia are more reliant on practitioner and public education to encourage appropriate antibiotic use. 26 KAP were included in the review and 16 were meta-analysable. KAP respondents in Australia and the UK are consistently more likely to report beliefs and behaviours that are not aligned with appropriate antibiotic use, compared to participants in similar studies conducted in Sweden. CONCLUSIONS Interactions between public knowledge, attitudes and their impacts on behaviours surrounding community use of antibiotics are complex and contingent. Despite a greater focus on raising public awareness in Australia and the UK, neither antibiotic consumption nor community knowledge and attitudes are changing significantly. Clearly public education campaigns can contribute to mitigating AMR. However, the relative success of policy approaches taken in Sweden suggests that practice level interventions may also be required to activate prescribers and the communities they serve to make substantive reductions in inappropriate antibiotic use.
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Affiliation(s)
- Olivia Hawkins
- Australian Centre for Health Engagement, Evidence and Values, The Faculty of the Arts, Social Sciences and Humanities, University of Wollongong, NSW, Australia
| | - Anna Mae Scott
- Institute for Evidence-Based Healthcare, Bond University, Queensland, Australia
| | - Amy Montgomery
- School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, NSW, Australia
| | - Bevan Nicholas
- Illawarra-Shoalhaven Local Health District, NSW Health, Wollongong, NSW, Australia
| | - Judy Mullan
- Centre for Health Research Illawarra Shoalhaven Population, Faculty of Science, Medicine and Health, University of Wollongong, NSW, Australia
- School of Medicine, Faculty of Science, Medicine and Health, University of Wollongong, NSW, Australia
| | - Antoine van Oijen
- Molecular Horizons, Faculty of Science, Medicine and Health, University of Wollongong, NSW, Australia
| | - Chris Degeling
- Australian Centre for Health Engagement, Evidence and Values, The Faculty of the Arts, Social Sciences and Humanities, University of Wollongong, NSW, Australia
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Degeling C, Brookes V, Hill T, Hall J, Rowles A, Tull C, Mullan J, Byrne M, Reynolds N, Hawkins O. Changes in the Framing of Antimicrobial Resistance in Print Media in Australia and the United Kingdom (2011-2020): A Comparative Qualitative Content and Trends Analysis. Antibiotics (Basel) 2021; 10:1432. [PMID: 34943644 PMCID: PMC8698020 DOI: 10.3390/antibiotics10121432] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 11/19/2021] [Accepted: 11/20/2021] [Indexed: 01/21/2023] Open
Abstract
Educating the public about antimicrobial resistance (AMR) is considered a key part of an optimal public health response. In both media depictions and policy discourses around health risks, how a problem is framed underpins public awareness and understanding, while also guiding opinions on what actions can and should be taken. Using a mixed methods approach we analyse newspaper content in Australia and the United Kingdom (UK) from 2011 to 2020 to track how causes, consequences and solutions to AMR are represented in countries with different policy approaches. Analyses demonstrate greater variability in the frames used in UK newspapers reflecting large hospital and community outbreaks and a sustained period of policy reform mid-decade. Newspapers in Australia focus more on AMR causes and consequences, highlighting the importance of scientific discovery, whereas UK coverage has greater discussion of the social and economic drivers of AMR and their associated solutions. Variations in the trends of different frames around AMR in UK newspapers indicate greater levels of public deliberation and debate around immediate and actionable solutions; whereas AMR has not had the same health and political impacts in Australia resulting in a media framing that potentially encourages greater public complacency about the issue.
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Affiliation(s)
- Chris Degeling
- Australian Centre for Health Engagement, Evidence and Values, The Faculty of Arts, Social Sciences and Humanities, University of Wollongong, Wollongong, NSW 2522, Australia; (J.H.); (O.H.)
| | - Victoria Brookes
- Sydney School of Veterinary Science Faculty of Science, The University of Sydney, Sydney, NSW 2006, Australia;
| | - Tarant Hill
- Illawarra-Shoalhaven Local Health District, NSW Health, Warrawong, NSW 2502, Australia;
| | - Julie Hall
- Australian Centre for Health Engagement, Evidence and Values, The Faculty of Arts, Social Sciences and Humanities, University of Wollongong, Wollongong, NSW 2522, Australia; (J.H.); (O.H.)
| | - Anastacia Rowles
- School of Health & Society, The Faculty of Arts, Social Sciences and Humanities, University of Wollongong, Wollongong, NSW 2522, Australia; (A.R.); (C.T.)
| | - Cassandra Tull
- School of Health & Society, The Faculty of Arts, Social Sciences and Humanities, University of Wollongong, Wollongong, NSW 2522, Australia; (A.R.); (C.T.)
| | - Judy Mullan
- Centre for Health Research Illawarra Shoalhaven Population, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, NSW 2522, Australia;
| | - Mitchell Byrne
- College of Human and Health Sciences, Charles Darwin University, Darwin, NT 0909, Australia;
| | - Nina Reynolds
- School of Business, Faculty of Business and Law, University of Wollongong, Wollongong, NSW 2522, Australia;
| | - Olivia Hawkins
- Australian Centre for Health Engagement, Evidence and Values, The Faculty of Arts, Social Sciences and Humanities, University of Wollongong, Wollongong, NSW 2522, Australia; (J.H.); (O.H.)
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Muller-Pebody B, Sinnathamby MA, Warburton F, Rooney G, Andrews N, Whitaker H, Henderson KL, Tsang C, Hopkins S, Pebody RG. Impact of the childhood influenza vaccine programme on antibiotic prescribing rates in primary care in England. Vaccine 2021; 39:6622-6627. [PMID: 34627625 DOI: 10.1016/j.vaccine.2021.09.069] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 09/25/2021] [Accepted: 09/28/2021] [Indexed: 11/26/2022]
Abstract
Vaccines are a key part of the global strategy to tackle antimicrobial resistance (AMR) since prevention of infection should reduce antibiotic use. England commenced national rollout of a live attenuated influenza vaccine (LAIV) programme for children aged 2-3 years together with a series of geographically discrete pilot areas for primary school age children in 2013 extending to older children in subsequent seasons. We investigated vaccine programme impact on community antibiotic prescribing rates. Antibiotic prescribing incidence rates for respiratory (RTI) and urinary tract infections (UTI; controls) were calculated at general practice (GP) level by age category (children<=10 years/adults) and season for LAIV pilot and non-pilot areas between 2013/14 and 2015/16. To estimate the LAIV (primary school age children only) intervention effect, a random effects model was fitted. A multivariable random-effects Poisson regression investigated the association of antibiotic prescribing rates in children with LAIV uptake (2-3-year-olds only) at GP practice level. RTI antibiotic prescribing rates for children <=10 years and adults showed clear seasonal trends and were lower in LAIV-pilot and non-pilot areas after the introduction of the LAIV programme in 2013. The reductions for RTI prescriptions (children) were similar (within 3%) in all areas, which coincided with the start the UK AMR strategy. Antibiotic prescribing was significantly (p < 0.0001) related to LAIV uptake in 2-3-year-olds with antibiotic prescribing reduced by 2.7% (95% CI: 2.1% to 3.4%) for every 10% increase in uptake. We found no evidence the LAIV programme for primary school age children resulted in reductions in RTI antibiotic prescribing, however we detected a significant inverse association between increased vaccine uptake in pre-school age children and antibiotic prescribing at GP level. The temporal association of reduced RTI and UTI antibiotic prescribing with the launch of the UK's AMR Strategy in 2013 highlights the importance of a multifaceted approach to tackle AMR.
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Affiliation(s)
- Berit Muller-Pebody
- Healthcare Associated Infections and Antimicrobial Resistance Division, National Infection Service, Public Health England (PHE), London, United Kingdom
| | - Mary A Sinnathamby
- Immunisation and Countermeasures, National Infection Service, Public Health England (PHE), London, United Kingdom.
| | - Fiona Warburton
- Statistics and Modelling Department, National Infection Service, Public Health England (PHE), London, United Kingdom
| | - Graeme Rooney
- Healthcare Associated Infections and Antimicrobial Resistance Division, National Infection Service, Public Health England (PHE), London, United Kingdom
| | - Nick Andrews
- Statistics and Modelling Department, National Infection Service, Public Health England (PHE), London, United Kingdom
| | - Heather Whitaker
- Statistics and Modelling Department, National Infection Service, Public Health England (PHE), London, United Kingdom
| | - Katherine L Henderson
- Healthcare Associated Infections and Antimicrobial Resistance Division, National Infection Service, Public Health England (PHE), London, United Kingdom
| | - Camille Tsang
- Immunisation and Countermeasures, National Infection Service, Public Health England (PHE), London, United Kingdom
| | - Susan Hopkins
- Healthcare Associated Infections and Antimicrobial Resistance Division, National Infection Service, Public Health England (PHE), London, United Kingdom
| | - Richard G Pebody
- Immunisation and Countermeasures, National Infection Service, Public Health England (PHE), London, United Kingdom
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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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Effect of antibiotic stewardship interventions in primary care on antimicrobial resistance of Escherichia coli bacteraemia in England (2013-18): a quasi-experimental, ecological, data linkage study. THE LANCET. INFECTIOUS DISEASES 2021; 21:1689-1700. [PMID: 34363774 PMCID: PMC8612938 DOI: 10.1016/s1473-3099(21)00069-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 01/19/2021] [Accepted: 01/29/2021] [Indexed: 02/06/2023]
Abstract
Background Antimicrobial resistance is a major global health concern, driven by overuse of antibiotics. We aimed to assess the effectiveness of a national antimicrobial stewardship intervention, the National Health Service (NHS) England Quality Premium implemented in 2015–16, on broad-spectrum antibiotic prescribing and Escherichia coli bacteraemia resistance to broad-spectrum antibiotics in England. Methods In this quasi-experimental, ecological, data linkage study, we used longitudinal data on bacteraemia for patients registered with a general practitioner in the English National Health Service and patients with E coli bacteraemia notified to the national mandatory surveillance programme between Jan 1, 2013, and Dec 31, 2018. We linked these data to data on antimicrobial susceptibility testing of E coli from Public Health England's Second-Generation Surveillance System. We did an ecological analysis using interrupted time-series analyses and generalised estimating equations to estimate the change in broad-spectrum antibiotics prescribing over time and the change in the proportion of E coli bacteraemia cases for which the causative bacteria were resistant to each antibiotic individually or to at least one of five broad-spectrum antibiotics (co-amoxiclav, ciprofloxacin, levofloxacin, moxifloxacin, ofloxacin), after implementation of the NHS England Quality Premium intervention in April, 2015. Findings Before implementation of the Quality Premium, the rate of antibiotic prescribing for all five broad-spectrum antibiotics was increasing at rate of 0·2% per month (incidence rate ratio [IRR] 1·002 [95% CI 1·000–1·004], p=0·046). After implementation of the Quality Premium, an immediate reduction in total broad-spectrum antibiotic prescribing rate was observed (IRR 0·867 [95% CI 0·837–0·898], p<0·0001). This effect was sustained until the end of the study period; a 57% reduction in rate of antibiotic prescribing was observed compared with the counterfactual situation (ie, had the Quality Premium not been implemented). In the same period, the rate of resistance to at least one broad-spectrum antibiotic increased at rate of 0·1% per month (IRR 1·001 [95% CI 0·999–1·003], p=0·346). On implementation of the Quality Premium, an immediate reduction in resistance rate to at least one broad-spectrum antibiotic was observed (IRR 0·947 [95% CI 0·918–0·977], p=0·0007). Although this effect was also sustained until the end of the study period, with a 12·03% reduction in resistance rate compared with the counterfactual situation, the overall trend remained on an upward trajectory. On examination of the long-term effect following implementation of the Quality Premium, there was an increase in the number of isolates resistant to at least one of the five broad-spectrum antibiotics tested (IRR 1·002 [1·000–1·003]; p=0·047). Interpretation Although interventions targeting antibiotic use can result in changes in resistance over a short period, they might be insufficient alone to curtail antimicrobial resistance. Funding National Institute for Health Research, Economic and Social Research Council, Rosetrees Trust, and The Stoneygate Trust.
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Andrews A, Budd EL, Hendrick A, Ashiru-Oredope D, Beech E, Hopkins S, Gerver S, Muller-Pebody B. Surveillance of Antibacterial Usage during the COVID-19 Pandemic in England, 2020. Antibiotics (Basel) 2021; 10:841. [PMID: 34356762 PMCID: PMC8300678 DOI: 10.3390/antibiotics10070841] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 05/19/2021] [Accepted: 07/08/2021] [Indexed: 11/16/2022] Open
Abstract
Changes in antibacterial prescribing during the COVID-19 pandemic were anticipated given that the clinical features of severe respiratory infection syndrome caused by SARS-CoV-2 mirror bacterial respiratory tract infections. Antibacterial consumption was measured in items/1000 population for primary care and in Defined Daily Doses (DDDs)/1000 admissions for secondary care in England from 2015 to October 2020. Interrupted time-series analyses were conducted to evaluate the effects of the pandemic on antibacterial consumption. In the community, the rate of antibacterial items prescribed decreased further in 2020 (by an extra 1.4% per month, 95% CI: -2.3 to -0.5) compared to before COVID-19. In hospitals, the volume of antibacterial use decreased during COVID-19 overall (-12.1% compared to pre-COVID, 95% CI: -19.1 to -4.4), although the rate of usage in hospitals increased steeply in April 2020. Use of antibacterials prescribed for respiratory infections and broad-spectrum antibacterials (predominately 'Watch' antibacterials in hospitals) increased in both settings. Overall volumes of antibacterial use at the beginning of the COVID-19 pandemic decreased in both primary and secondary settings, although there were increases in the rate of usage in hospitals in April 2020 and in specific antibacterials. This highlights the importance of antimicrobial stewardship during pandemics to ensure appropriate prescribing and avoid negative consequences on patient outcomes and antimicrobial resistance.
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Affiliation(s)
- Amelia Andrews
- Healthcare-Associated Infection and Antimicrobial Resistance Division, Public Health England, London NW9 5EQ, UK; (E.L.B.); (A.H.); (D.A.-O.); (S.H.); (S.G.); (B.M.-P.)
- National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford OX3 9DU, UK
- National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London W12 0NN, UK
| | - Emma L. Budd
- Healthcare-Associated Infection and Antimicrobial Resistance Division, Public Health England, London NW9 5EQ, UK; (E.L.B.); (A.H.); (D.A.-O.); (S.H.); (S.G.); (B.M.-P.)
| | - Aoife Hendrick
- Healthcare-Associated Infection and Antimicrobial Resistance Division, Public Health England, London NW9 5EQ, UK; (E.L.B.); (A.H.); (D.A.-O.); (S.H.); (S.G.); (B.M.-P.)
| | - Diane Ashiru-Oredope
- Healthcare-Associated Infection and Antimicrobial Resistance Division, Public Health England, London NW9 5EQ, UK; (E.L.B.); (A.H.); (D.A.-O.); (S.H.); (S.G.); (B.M.-P.)
- National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London W12 0NN, UK
| | | | - Susan Hopkins
- Healthcare-Associated Infection and Antimicrobial Resistance Division, Public Health England, London NW9 5EQ, UK; (E.L.B.); (A.H.); (D.A.-O.); (S.H.); (S.G.); (B.M.-P.)
- National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford OX3 9DU, UK
- National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London W12 0NN, UK
| | - Sarah Gerver
- Healthcare-Associated Infection and Antimicrobial Resistance Division, Public Health England, London NW9 5EQ, UK; (E.L.B.); (A.H.); (D.A.-O.); (S.H.); (S.G.); (B.M.-P.)
- National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford OX3 9DU, UK
- National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London W12 0NN, UK
| | - Berit Muller-Pebody
- Healthcare-Associated Infection and Antimicrobial Resistance Division, Public Health England, London NW9 5EQ, UK; (E.L.B.); (A.H.); (D.A.-O.); (S.H.); (S.G.); (B.M.-P.)
- National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford OX3 9DU, UK
- National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London W12 0NN, UK
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Rolf von den Baumen T, Crosby M, Tadrous M, Schwartz KL, Gomes T. Measuring the impacts of the Using Antibiotics Wisely campaign on Canadian community utilization of oral antibiotics for respiratory tract infections: a time-series analysis from 2015 to 2019. J Antimicrob Chemother 2021; 76:2472-2478. [PMID: 34223899 DOI: 10.1093/jac/dkab205] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 05/24/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND On 1 November 2018, Choosing Wisely Canada launched their Using Antibiotics Wisely primary care campaign, which aimed to reduce unnecessary antibiotic prescriptions for respiratory tract infections (RTIs) through educational tools for patients and providers. OBJECTIVES We explored the impact of this campaign on antibiotic utilization in Canada. METHODS We conducted a population-based study in Canada between January 2015 and December 2019. We used interventional autoregressive integrated moving average models to study the impact of the Using Antibiotics Wisely campaign on the prescribing rate (prescriptions per 1000 population) of RTI-indicated antibiotics. We analysed prescription rates overall and stratified by age group, drug class and province, in each month over the study period. RESULTS There was a 1.5% reduction in the annual prescribing rate of RTI-indicated antibiotics over the study period, which was generally consistent across age groups and provinces. Following the 2018 Using Antibiotics Wisely clinician toolkit release, we observed no significant change in RTI-indicated antibiotic prescribing rates nationally (P = 0.13). This was consistent by age group (children, P = 0.91; adults, P = 0.58; and older adults, P = 0.67) and drug class (narrow-spectrum penicillins, P = 0.88; macrolides, P = 0.85; broad-spectrum penicillins, P = 0.60; cephalosporins, P = 0.45; tetracyclines, P = 0.55; and fluoroquinolones, P = 0.98). In our secondary analysis of prescription rates in provinces that self-identified as prioritizing Using Antibiotics Wisely, we observed no significant change following the launch of the campaign. CONCLUSIONS The introduction of the Using Antibiotics Wisely campaign in Canada has not caused a significant change in short-term antibiotic prescribing patterns. Community antibiotic stewardship campaigns that include components beyond education may be more impactful.
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Affiliation(s)
| | - Michael Crosby
- Leslie Dan Faculty of Pharmacy at the University of Toronto, Toronto, Ontario, Canada
| | - Mina Tadrous
- Leslie Dan Faculty of Pharmacy at the University of Toronto, Toronto, Ontario, Canada.,Women's College Hospital Research Institute, Toronto, Ontario, Canada
| | - Kevin L Schwartz
- Public Health Ontario, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Unity Health Toronto, Toronto, Ontario, Canada
| | - Tara Gomes
- Leslie Dan Faculty of Pharmacy at the University of Toronto, Toronto, Ontario, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation at the University of Toronto, Toronto, Ontario, Canada
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20
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Borek AJ, Anthierens S, Allison R, McNulty CAM, Lecky DM, Costelloe C, Holmes A, Butler CC, Walker AS, Tonkin-Crine S. How did a Quality Premium financial incentive influence antibiotic prescribing in primary care? Views of Clinical Commissioning Group and general practice professionals. J Antimicrob Chemother 2021; 75:2681-2688. [PMID: 32573692 DOI: 10.1093/jac/dkaa224] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 04/24/2020] [Accepted: 04/27/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The Quality Premium (QP) was introduced for Clinical Commissioning Groups (CCGs) in England to optimize antibiotic prescribing, but it remains unclear how it was implemented. OBJECTIVES To understand responses to the QP and how it was perceived to influence antibiotic prescribing. METHODS Semi-structured telephone interviews were conducted with 22 CCG and 19 general practice professionals. Interviews were analysed thematically. RESULTS The findings were organized into four categories. (i) Communication: this was perceived as unstructured and infrequent, and CCG professionals were unsure whether they received QP funding. (ii) Implementation: this was influenced by available local resources and competing priorities, with multifaceted and tailored strategies seen as most helpful for engaging general practices. Many antimicrobial stewardship (AMS) strategies were implemented independently from the QP, motivated by quality improvement. (iii) Mechanisms: the QP raised the priority of AMS nationally and locally, and provided prescribing targets to aim for and benchmark against, but money was not seen as reinvested into AMS. (iv) Impact and sustainability: the QP was perceived as successful, but targets were considered challenging for a minority of CCGs and practices due to contextual factors (e.g. deprivation, understaffing). CCG professionals were concerned with potential discontinuation of the QP and prescribing rates levelling off. CONCLUSIONS CCG and practice professionals expressed positive views of the QP and associated prescribing targets and feedback. The QP helped influence change mainly by raising the priority of AMS and defining change targets rather than providing additional funding. To maximize impact, behavioural mechanisms of financial incentives should be considered pre-implementation.
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Affiliation(s)
- Aleksandra J Borek
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Rosalie Allison
- Primary Care and Interventions Unit, Public Health England, Gloucester, UK
| | | | - Donna M Lecky
- Primary Care and Interventions Unit, Public Health England, Gloucester, UK
| | - Ceire Costelloe
- Faculty of Medicine, School of Public Health, Imperial College London, London, UK
| | - Alison Holmes
- Department of Infectious Diseases, Imperial College London, London, UK.,National Institute for Health Research (NIHR) Health Protection Research Unit (HPRU) in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - A Sarah Walker
- National Institute for Health Research (NIHR) Health Protection Research Unit (HPRU) in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.,National Institute for Health Research (NIHR) Health Protection Research Unit (HPRU) in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
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21
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Jenkins TC, Tamma PD. Thinking Beyond the "Core" Antibiotic Stewardship Interventions: Shifting the Onus for Appropriate Antibiotic Use from Stewardship Teams to Prescribing Clinicians. Clin Infect Dis 2021; 72:1457-1462. [PMID: 32667974 DOI: 10.1093/cid/ciaa1003] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 07/10/2020] [Indexed: 01/31/2023] Open
Abstract
United States guidance for hospital antibiotic stewardship has emphasized prospective audit and feedback and prior authorization of select antibiotics as core interventions. These remain the most common interventions implemented by stewardship programs. Although these approaches have been shown to reduce unnecessary antibiotic use, they incorrectly put the onus for appropriate antibiotic use on the stewardship team rather than the prescribing clinician. We propose that a primary focus of stewardship programs should be implementation of broader interventions that engage frontline clinicians and equip them with tools to integrate antibiotic stewardship into their own daily practice, thus reducing the need for day-to-day stewardship team oversite. We discuss a framework of broader interventions and policies that will facilitate this paradigm shift.
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Affiliation(s)
- Timothy C Jenkins
- Department of Medicine and Division of Infectious Diseases, Denver Health, Denver, Colorado, USA.,Department of Patient Safety and Quality, Denver Health, Denver, Colorado, USA.,Department of Medicine and Division of Infectious Diseases, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Pranita D Tamma
- Department of Pediatrics, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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22
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Gulliford MC, Charlton J, Boiko O, Winter JR, Rezel-Potts E, Sun X, Burgess C, McDermott L, Bunce C, Shearer J, Curcin V, Fox R, Hay AD, Little P, Moore MV, Ashworth M. Safety of reducing antibiotic prescribing in primary care: a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2021. [DOI: 10.3310/hsdr09090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background
The threat of antimicrobial resistance has led to intensified efforts to reduce antibiotic utilisation, but serious bacterial infections are increasing in frequency.
Objectives
To estimate the risks of serious bacterial infections in association with lower antibiotic prescribing and understand stakeholder views with respect to safe antibiotic reduction.
Design
Mixed-methods research was undertaken, including a qualitative interview study of patient and prescriber views that informed a cohort study and a decision-analytic model, using primary care electronic health records. These three work packages were used to design an application (app) for primary care prescribers.
Data sources
The Clinical Practice Research Datalink.
Setting
This took place in UK general practices.
Participants
A total of 706 general practices with 66.2 million person-years of follow-up from 2002 to 2017 and antibiotic utilisation evaluated for 671,830 registered patients. The qualitative study included 31 patients and 30 health-care professionals from primary care.
Main outcome measures
Sepsis and localised bacterial infections.
Results
Patients were concerned about antimicrobial resistance and the side effects, as well as the benefits, of antibiotic treatment. Prescribers viewed the onset of sepsis as the most concerning potential outcome of reduced antibiotic prescribing. More than 40% of antibiotic prescriptions in primary care had no coded indication recorded across both Vision® and EMIS® practice systems. Antibiotic prescribing rates varied widely between general practices, but there was no evidence that serious bacterial infections were less frequent at higher prescribing practices (adjusted rate ratio for 20% increase in prescribing 1.03, 95% confidence interval 1.00 to 1.06; p = 0.074). The probability of sepsis was lower if an antibiotic was prescribed at an infection consultation, and the number of antibiotic prescriptions required to prevent one episode of sepsis (i.e. the number needed to treat) decreased with age. For those aged 0–4 years, the number needed to treat was 29,773 (95% uncertainty interval 18,458 to 71,091) in boys and 27,014 (95% uncertainty interval 16,739 to 65,709) in girls. For those aged > 85 years, the number needed to treat was 262 (95% uncertainty interval 236 to 293) in men and 385 (95% uncertainty interval 352 to 421) in women. Frailty was associated with a greater risk of sepsis and a smaller number needed to treat. For severely frail patients aged 55–64 years, the number needed to treat was 247 (95% uncertainty interval 156 to 459) for men and 343 (95% uncertainty interval 234 to 556) for women. At all ages, the probability of sepsis was greatest for urinary tract infection, followed by skin infection and respiratory tract infection. The numbers needed to treat were generally smaller for the period 2014–17, when sepsis was diagnosed more frequently. The results are available using an app that we developed to provide primary care prescribers with stratified risk estimates during infection consultations.
Limitations
Analyses were based on non-randomised comparisons. Infection episodes and antibiotic prescribing are poorly documented in primary care.
Conclusions
Antibiotic treatment is generally associated with lower risks, but the most serious bacterial infections remain infrequent even without antibiotic treatment. This research identifies risk strata in which antibiotic prescribing can be more safely reduced.
Future work
The software developed from this research may be further developed and investigated for antimicrobial stewardship effect.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 9. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Martin C Gulliford
- School of Population Health and Environmental Sciences, King’s College London, London, UK
- National Institute for Health Research Biomedical Research Centre, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Judith Charlton
- School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Olga Boiko
- School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Joanne R Winter
- School of Population Health and Environmental Sciences, King’s College London, London, UK
- National Institute for Health Research Biomedical Research Centre, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Emma Rezel-Potts
- School of Population Health and Environmental Sciences, King’s College London, London, UK
- National Institute for Health Research Biomedical Research Centre, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Xiaohui Sun
- School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Caroline Burgess
- School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Lisa McDermott
- School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Catey Bunce
- School of Population Health and Environmental Sciences, King’s College London, London, UK
- National Institute for Health Research Biomedical Research Centre, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - James Shearer
- School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Vasa Curcin
- School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Robin Fox
- Bicester Health Centre, Bicester, UK
| | - Alastair D Hay
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | - Paul Little
- Primary Care Research Group, University of Southampton, Southampton, UK
| | - Michael V Moore
- Primary Care Research Group, University of Southampton, Southampton, UK
| | - Mark Ashworth
- School of Population Health and Environmental Sciences, King’s College London, London, UK
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23
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Tomas A, Pavlović N, Stilinović N, Horvat O, Paut-Kusturica M, Dugandžija T, Tomić Z, Sabo A. Increase and Change in the Pattern of Antibiotic Use in Serbia (2010-2019). Antibiotics (Basel) 2021; 10:397. [PMID: 33916896 PMCID: PMC8067575 DOI: 10.3390/antibiotics10040397] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 04/01/2021] [Accepted: 04/05/2021] [Indexed: 01/01/2023] Open
Abstract
The aim of this study was to determine and describe trends in antibiotics utilization in Serbia over a ten-year period. Data were retrieved from publicly available annual reports (2010-2019). The results were expressed as Defined Daily Dose (DDD) per 1000 inhabitants per day (DID). All calculations were performed using the DDD values for the 2020 Anatomical Therapeutic Chemical/Defined Daily Dose (ATC/DDD) version for each year of the study, to account for the DDD changes during the study period. Antibiotics were classified using the WHO Access, Watch, Reserve (AWaRe) classification. Total utilization of antibacterials for systemic use increased from 17.25 DID in 2010 to 28.65 DID in 2019. A statistically significant increasing trend in the use of the Watch category antibiotics was observed. A tendency towards use of broad-spectrum antibiotics, apparent by a statistically significant increase in the rate of utilization of broad-spectrum macrolides, quinolones and third-generation cephalosporins vs. narrow-spectrum ones, as well as a significant increasing trend in the use of quinolones was identified. Total antibiotic utilization was found to be well above the European average. Several specific problem areas were identified, which requires further efforts to improve antibiotic prescribing. The present study provides the information needed to facilitate antibiotic stewardship in Serbia further and proposes specific interventions to optimize antibiotic use in Serbia.
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Affiliation(s)
- Ana Tomas
- Department of Pharmacology, Toxicology and Clinical Pharmacology, Faculty of Medicine, University of Novi Sad, Hajduk Veljkova 3, 21000 Novi Sad, Serbia; (N.S.); (O.H.); (M.P.-K.); (Z.T.); (A.S.)
| | - Nebojša Pavlović
- Department of Pharmacy, Faculty of Medicine, University of Novi Sad, Hajduk Veljkova 3, 21000 Novi Sad, Serbia;
| | - Nebojša Stilinović
- Department of Pharmacology, Toxicology and Clinical Pharmacology, Faculty of Medicine, University of Novi Sad, Hajduk Veljkova 3, 21000 Novi Sad, Serbia; (N.S.); (O.H.); (M.P.-K.); (Z.T.); (A.S.)
| | - Olga Horvat
- Department of Pharmacology, Toxicology and Clinical Pharmacology, Faculty of Medicine, University of Novi Sad, Hajduk Veljkova 3, 21000 Novi Sad, Serbia; (N.S.); (O.H.); (M.P.-K.); (Z.T.); (A.S.)
| | - Milica Paut-Kusturica
- Department of Pharmacology, Toxicology and Clinical Pharmacology, Faculty of Medicine, University of Novi Sad, Hajduk Veljkova 3, 21000 Novi Sad, Serbia; (N.S.); (O.H.); (M.P.-K.); (Z.T.); (A.S.)
| | - Tihomir Dugandžija
- Department of Epidemiology, Faculty of Medicine, University of Novi Sad, Hajduk Veljkova 3, 21000 Novi Sad, Serbia;
- Oncology Institute of Vojvodina, Put doktora Goldmana 4, 21204 Sremska Kamenica, Serbia
| | - Zdenko Tomić
- Department of Pharmacology, Toxicology and Clinical Pharmacology, Faculty of Medicine, University of Novi Sad, Hajduk Veljkova 3, 21000 Novi Sad, Serbia; (N.S.); (O.H.); (M.P.-K.); (Z.T.); (A.S.)
| | - Ana Sabo
- Department of Pharmacology, Toxicology and Clinical Pharmacology, Faculty of Medicine, University of Novi Sad, Hajduk Veljkova 3, 21000 Novi Sad, Serbia; (N.S.); (O.H.); (M.P.-K.); (Z.T.); (A.S.)
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24
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Zhu N, Aylin P, Rawson T, Gilchrist M, Majeed A, Holmes A. Investigating the impact of COVID-19 on primary care antibiotic prescribing in North West London across two epidemic waves. Clin Microbiol Infect 2021; 27:S1198-743X(21)00082-3. [PMID: 33601010 PMCID: PMC7884225 DOI: 10.1016/j.cmi.2021.02.007] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 12/30/2020] [Accepted: 02/06/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVES We investigated the impact of COVID-19 and national pandemic response on primary care antibiotic prescribing in London. METHODS Individual prescribing records between 2015 and 2020 for 2 million residents in north west London were analysed. Prescribing records were linked to SARS-CoV-2 test results. Prescribing volumes, in total, and stratified by patient characteristics, antibiotic class and AWaRe classification, were investigated. Interrupted time series analysis was performed to detect measurable change in the trend of prescribing volume since the national lockdown in March 2020, immediately before the first COVID-19 peak in London. RESULTS Records covering 366 059 patients, 730 001 antibiotic items and 848 201 SARS-CoV-2 tests between January and November 2020 were analysed. Before March 2020, there was a background downward trend (decreasing by 584 items/month) in primary care antibiotic prescribing. This reduction rate accelerated to 3504 items/month from March 2020. This rate of decrease was sustained beyond the initial peak, continuing into winter and the second peak. Despite an overall reduction in prescribing volume, co-amoxiclav, a broad-spectrum "Access" antibiotic, prescribing rose by 70.1% in patients aged 50 and older from February to April. Commonly prescribed antibiotics within 14 days of a positive SARS-CoV-2 test were amoxicillin (863/2474, 34.9%) and doxycycline (678/2474, 27.4%). This aligned with national guidelines on management of community pneumonia of unclear cause. The proportion of "Watch" antibiotics used decreased during the peak in COVID-19. DISCUSSION A sustained reduction in community antibiotic prescribing has been observed since the first lockdown. Investigation of community-onset infectious diseases and potential unintended consequences of reduced prescribing is urgently needed.
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Affiliation(s)
- Nina Zhu
- National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
| | - Paul Aylin
- National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK; Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Timothy Rawson
- National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK; Centre for Antimicrobial Optimisation, Imperial College London, London, UK; Department of Infectious Diseases, Imperial College London, South Kensington, UK; Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - Mark Gilchrist
- National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK; Centre for Antimicrobial Optimisation, Imperial College London, London, UK; Department of Infectious Diseases, Imperial College London, South Kensington, UK; Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - Azeem Majeed
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Alison Holmes
- National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK; Centre for Antimicrobial Optimisation, Imperial College London, London, UK; Department of Infectious Diseases, Imperial College London, South Kensington, UK; Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK.
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25
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Worley G, Almoudaris A, Bassett P, Segal J, Akbar A, Ghosh S, Aylin P, Faiz O. Colectomy rates for ulcerative colitis in England 2003-2016. Aliment Pharmacol Ther 2021; 53:484-498. [PMID: 33264468 DOI: 10.1111/apt.16202] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 02/04/2020] [Accepted: 11/17/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Temporal trends in colectomy rate for ulcerative colitis (UC) are particularly relevant in the current era of published IBD standards and changing approach to salvage of acute severe disease. AIMS To investigate temporal trends in colectomy for UC using English population data. METHODS The Hospital Episode Statistics (HES) were interrogated between 2003-2016 with two patient groups investigated independently. An 'emergency' cohort: emergency UC admission ≥ three days, age ≥18 and a 'total population' cohort: all English patients undergoing colectomy for UC. Mixed methods analyses were utilised. RESULTS Emergency cohort: 37 981 patients, 49% female, median age 46. The one- and three-year incidence of colectomy after acute admission was 0.17 and 0.21. Interrupted time series (ITS) analysis suggested reductions in colectomy rate of 4% per year after 2008 at 30 and 90 days following emergency admission, with no significant reduction ≥1 year. Mortality and laparoscopy rates improved when avoiding colectomy at index and emergency admissions; however, the proportion of emergency colectomies after salvage at index admission significantly increased during the study period. Total population cohort: 17 580 patients underwent colectomy for UC between 2003 and 2016, demonstrating a 3.1% annual reduction in total and elective colectomies after 2008, but no reduction in emergency colectomies. CONCLUSION Reductions in short-term colectomy rates after emergency admission for UC do not persist beyond one year. Emergency colectomy rates remain unchanged. Reduced rates are probably due to multi-modal improvements in IBD care. A lack of data regarding disease severity precludes further interpretation of appropriate medical salvage and timely surgery.
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Affiliation(s)
- Guy Worley
- The Surgical Epidemiology, Trials and Outcome Centre, St Mark's Academic Institute, London, UK.,Department of Surgery and Cancer, Imperial College, London, UK
| | - Alex Almoudaris
- The Surgical Epidemiology, Trials and Outcome Centre, St Mark's Academic Institute, London, UK.,Department of Surgery and Cancer, Imperial College, London, UK
| | - Paul Bassett
- St Mark's Hospital and Academic Institute, London, UK.,Statsconsultancy Ltd, Bucks, UK
| | - Jonathan Segal
- The Surgical Epidemiology, Trials and Outcome Centre, St Mark's Academic Institute, London, UK.,Department of Surgery and Cancer, Imperial College, London, UK
| | - Ayesha Akbar
- Department of Surgery and Cancer, Imperial College, London, UK.,St Mark's Hospital and Academic Institute, London, UK
| | - Subrata Ghosh
- Institute of Translational Medicine, NIHR Biomedical Research Centre, University of Birmingham, Birmingham, UK
| | - Paul Aylin
- Dr Foster Unit, Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Omar Faiz
- The Surgical Epidemiology, Trials and Outcome Centre, St Mark's Academic Institute, London, UK.,Department of Surgery and Cancer, Imperial College, London, UK
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26
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Zhu NJ, McLeod M, McNulty CAM, Lecky DM, Holmes AH, Ahmad R. Trends in Antibiotic Prescribing in Out-of-Hours Primary Care in England from January 2016 to June 2020 to Understand Behaviours during the First Wave of COVID-19. Antibiotics (Basel) 2021; 10:32. [PMID: 33401408 PMCID: PMC7824631 DOI: 10.3390/antibiotics10010032] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 12/24/2020] [Accepted: 12/25/2020] [Indexed: 12/18/2022] Open
Abstract
We describe the trend of antibiotic prescribing in out-of-hours (OOH) general practices (GP) before and during England's first wave of the COVID-19 pandemic. We analysed practice-level prescribing records between January 2016 to June 2020 to report the trends for the total prescribing volume, prescribing of broad-spectrum antibiotics and key agents included in the national Quality Premium. We performed a time-series analysis to detect measurable changes in the prescribing volume associated with COVID-19. Before COVID-19, the total prescribing volume and the percentage of broad-spectrum antibiotics continued to decrease in-hours (IH). The prescribing of broad-spectrum antibiotics was higher in OOH (OOH: 10.1%, IH: 8.7%), but a consistent decrease in the trimethoprim-to-nitrofurantoin ratio was observed OOH. The OOH antibiotic prescribing volume diverged from the historical trend in March 2020 and started to decrease by 5088 items per month. Broad-spectrum antibiotic prescribing started to increase in OOH and IH. In OOH, co-amoxiclav and doxycycline peaked in March to May in 2020, which was out of sync with seasonality peaks (Winter) in previous years. While this increase might be explained by the implementation of the national guideline to use co-amoxiclav and doxycycline to manage pneumonia in the community during COVID-19, further investigation is required to see whether the observed reduction in OOH antibiotic prescribing persists and how this reduction might influence antimicrobial resistance and patient outcomes.
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Affiliation(s)
- Nina J. Zhu
- National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London W12 0NN, UK; (N.J.Z.); (M.M.); (A.H.H.)
| | - Monsey McLeod
- National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London W12 0NN, UK; (N.J.Z.); (M.M.); (A.H.H.)
- Centre for Medication Safety and Service Quality, Pharmacy Department, Imperial College Healthcare NHS Trust, London W12 0NN, UK
- National Institute for Health Research, Imperial Patient Safety Translational Research Centre, Imperial College London, London W2 1PG, UK
| | - Cliodna A. M. McNulty
- Primary Care Unit, Public Health England, Gloucestershire GL1 1DQ, UK; (C.A.M.M.); (D.M.L.)
| | - Donna M. Lecky
- Primary Care Unit, Public Health England, Gloucestershire GL1 1DQ, UK; (C.A.M.M.); (D.M.L.)
| | - Alison H. Holmes
- National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London W12 0NN, UK; (N.J.Z.); (M.M.); (A.H.H.)
- Centre for Antimicrobial Optimisation, Imperial College London, London W12 0NN, UK
- Department of Infectious Diseases, Imperial College London, London SW7 2AZ, UK
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London W12 0NN, UK
| | - Raheelah Ahmad
- National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London W12 0NN, UK; (N.J.Z.); (M.M.); (A.H.H.)
- Division of Health Services Research and Management, School of Health Sciences, University of London, London EC1V 0HB, UK
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27
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Thilly N, Pereira O, Schouten J, Hulscher ME, Pulcini C. Proxy indicators to estimate appropriateness of antibiotic prescriptions by general practitioners: a proof-of-concept cross-sectional study based on reimbursement data, north-eastern France 2017. ACTA ACUST UNITED AC 2020; 25. [PMID: 32672150 PMCID: PMC7364760 DOI: 10.2807/1560-7917.es.2020.25.27.1900468] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Background In most countries, including France, data on clinical indications for outpatient antibiotic prescriptions are not available, making it impossible to assess appropriateness of antibiotic use at prescription level. Aim Our objectives were to: (i) propose proxy indicators (PIs) to estimate appropriateness of antibiotic use at general practitioner (GP) level based on routine reimbursement data; and (ii) assess PIs’ performance scores and their clinimetric properties using a large regional reimbursement database. Methods A recent systematic literature review on quality indicators was the starting point for defining a set of PIs, taking French national guidelines into account. We performed a cross-sectional study analysing National Health Insurance data (available at prescriber and patient levels) on antibiotics prescribed by GPs in 2017 for individuals living in north-eastern France. We measured performance scores of the PIs and their case-mix stability, and tested their measurability, applicability, and room for improvement (clinimetric properties). Results The 3,087 GPs included in this study prescribed a total of 2,077,249 antibiotic treatments. We defined 10 PIs with specific numerators, denominators and targets. Performance was low for almost all indicators ranging from 9% to 75%, with values < 30% for eight of 10 indicators. For all PIs, we found large variation between GPs and patient populations (case-mix stability). Regarding clinimetric properties, all PIs were measurable, applicable, and showed high improvement potential. Conclusions The set of 10 PIs showed satisfactory clinimetric properties and might be used to estimate appropriateness of antibiotic prescribing in primary care, in an automated way within antibiotic stewardship programmes.
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Affiliation(s)
- Nathalie Thilly
- Université de Lorraine, Centre Hospitalier Régional Universitaire de Nancy (CHRU-Nancy), Département Méthodologie, Promotion, Investigation, Nancy, France.,Université de Lorraine, Adaptation, mesure et évaluation en santé. Approches interdisciplinaires (APEMAC), Nancy, France
| | - Ouarda Pereira
- Direction Régionale du Service Médical du Nord-Est, Nancy, France
| | - Jeroen Schouten
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Nijmegen, the Netherlands
| | - Marlies Ejl Hulscher
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Nijmegen, the Netherlands
| | - Céline Pulcini
- Université de Lorraine, Centre Hospitalier Régional Universitaire de Nancy (CHRU-Nancy), Département de maladies infectieuses, Nancy, France.,Université de Lorraine, Adaptation, mesure et évaluation en santé. Approches interdisciplinaires (APEMAC), Nancy, France
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Borek AJ, Anthierens S, Allison R, Mcnulty CAM, Anyanwu PE, Costelloe C, Walker AS, Butler CC, Tonkin-Crine S. Social and Contextual Influences on Antibiotic Prescribing and Antimicrobial Stewardship: A Qualitative Study with Clinical Commissioning Group and General Practice Professionals. Antibiotics (Basel) 2020; 9:E859. [PMID: 33271843 PMCID: PMC7759918 DOI: 10.3390/antibiotics9120859] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 11/20/2020] [Accepted: 11/26/2020] [Indexed: 12/25/2022] Open
Abstract
Antibiotic prescribing in England varies considerably between Clinical Commissioning Groups (CCGs) and general practices. We aimed to assess social and contextual factors affecting antibiotic prescribing and engagement with antimicrobial stewardship (AMS) initiatives. Semi-structured telephone interviews were conducted with 22 CCG professionals and 19 general practice professionals. Interviews were audio-recorded, transcribed, and analyzed thematically. Social/contextual influences were grouped into the following four categories: (1) Immediate context, i.e., patients' social characteristics (e.g., deprivation and culture), clinical factors, and practice and clinician characteristics (e.g., "struggling" with staff shortage/turnover) were linked to higher prescribing. (2) Wider context, i.e., pressures on the healthcare system, limited resources, and competing priorities were seen to reduce engagement with AMS. (3) Collaborative and whole system approaches, i.e., communication, multidisciplinary networks, leadership, and teamwork facilitated prioritizing AMS, learning, and consistency. (4) Relativity of appropriate prescribing, i.e., "high" or "appropriate" prescribing was perceived as relative, depending on comparators, and disregarding different contexts, but social norms around antibiotic use among professionals and patients seemed to be changing. Further optimization of antibiotic prescribing would benefit from addressing social/contextual factors and addressing wider health inequalities, not only targeting individual clinicians. Tailoring and adapting to local contexts and constraints, ensuring adequate time and resources for AMS, and collaborative, whole system approaches to promote consistency may help promote AMS.
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Affiliation(s)
- Aleksandra J. Borek
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK; (C.C.B.); (S.T.-C.)
| | - Sibyl Anthierens
- Department of Family Medicine and Population Health, University of Antwerp, 2610 Antwerp, Belgium;
| | - Rosalie Allison
- Primary Care and Interventions Unit, Public Health England, Gloucester GL1 1DQ, UK; (R.A.); (C.A.M.M.)
| | - Cliodna A. M. Mcnulty
- Primary Care and Interventions Unit, Public Health England, Gloucester GL1 1DQ, UK; (R.A.); (C.A.M.M.)
| | - Philip E. Anyanwu
- Department of Primary Care and Public Health, Imperial College London, London W6 8RP, UK; (P.E.A.); (C.C.)
- School of Medicine, College of Biomedical and Life Sciences, Cardiff University, Cardiff CF14 4XN, UK
| | - Ceire Costelloe
- Department of Primary Care and Public Health, Imperial College London, London W6 8RP, UK; (P.E.A.); (C.C.)
| | - Ann Sarah Walker
- National Institute for Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Oxford OX3 9DU, UK;
- National Institute for Health Research Biomedical Research Centre, Oxford OX3 9DU, UK
- Nuffield Department of Medicine, University of Oxford, Oxford OX3 9DU, UK
| | - Christopher C. Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK; (C.C.B.); (S.T.-C.)
- National Institute for Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Oxford OX3 9DU, UK;
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK; (C.C.B.); (S.T.-C.)
- National Institute for Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Oxford OX3 9DU, UK;
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Impact of national guidelines for antimicrobial stewardship to reduce antibiotic use in upper respiratory tract infection and gastroenteritis. Infect Control Hosp Epidemiol 2020; 42:280-286. [DOI: 10.1017/ice.2020.427] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
AbstractObjective:To examine whether the issue and dissemination of national guidelines in the Manual of Antimicrobial Stewardship had an impact on reducing antibiotic use for acute respiratory tract infection (ARTI) and gastroenteritis.Method:An interrupted time-series analysis was performed using a large nationwide database from June 2016 to June 2018. Outpatients with ARTI or gastroenteritis aged ≥6 years were identified. The outcome measures were any antibiotic use and broad-spectrum antibiotic use. The season-adjusted changes in the rate of antibiotic prescriptions for 2 periods before and after the guideline issue date were examined.Results:There were 13,177,735 patients with ARTI and 300,565 patients with gastroenteritis during the study period. Among patients with ARTI, there was a significant downward trend in antibiotic use during the 2-year study period (−0.06% per week; 95% CI, −0.07% to −0.04%). However, there was no significant change in trends of antibiotic use between the pre-issue period and post-issue period (trend difference, −0.01% per week; 95% CI, −0.10% to 0.07%). Similarly, for patients with gastroenteritis, there was no significant change in the trends of antibiotic use between the pre-issue period and post-issue period (trend difference, −0.02% per week; 95% CI, −0.04% to 0.01%). Similar associations were observed in analyses for broad-spectrum antibiotic use.Conclusions:Despite the issue of national guidelines to promote the appropriate use of antibiotics, there were no significant changes in trends of antibiotic use for outpatients with ARTI or gastroenteritis between the pre-issue and post-issue periods.
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Diagnosis and Management of UTI in Primary Care Settings-A Qualitative Study to Inform a Diagnostic Quick Reference Tool for Women Under 65 Years. Antibiotics (Basel) 2020; 9:antibiotics9090581. [PMID: 32906671 PMCID: PMC7559568 DOI: 10.3390/antibiotics9090581] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 08/22/2020] [Accepted: 08/24/2020] [Indexed: 11/17/2022] Open
Abstract
Background: To inform interventions to improve antimicrobial use in urinary tract infections (UTIs) and contribute to a reduction in Escherichia coli bloodstream infection, we explored factors influencing the diagnosis and management of UTIs in primary care. Design: Semi-structured focus groups informed by the Theoretical Domains Framework. Setting: General practice (GP) surgeries in two English clinical commissioning groups (CCGs), June 2017 to March 2018. Participants: A total of 57 GP staff within 8 focus groups. Results: Staff were very aware of common UTI symptoms and nitrofurantoin as first-line treatment, but some were less aware about when to send a urine culture, second-line and non-antibiotic management, and did not probe for signs and symptoms to specifically exclude vaginal causes or pyelonephritis before prescribing. Many consultations were undertaken over the phone, many by nurse practitioners, and followed established protocols that often included urine dipsticks and receptionists. Patient expectations increased use of urine dipsticks, and immediate and 5 days courses of antibiotics. Management decisions were also influenced by patient co-morbidities. No participants had undertaken recent UTI audits. Patient discussions around antibiotic resistance and back-up antibiotics were uncommon compared to consultations for respiratory infections. Conclusions: Knowledge and skill gaps could be addressed with education and clear, accessible, UTI diagnostic and management guidance and protocols that are also appropriate for phone consultations. Public antibiotic campaigns and patient-facing information should cover UTIs, non-pharmaceutical recommendations for "self-care", prevention and rationale for 3 days antibiotic courses. Practices should be encouraged to audit UTI management.
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Anyanwu PE, Pouwels K, Walker A, Moore M, Majeed A, Hayhoe BWJ, Tonkin-Crine S, Borek A, Hopkins S, Mcleod M, Costelloe C. Investigating the mechanism of impact and differential effect of the Quality Premium scheme on antibiotic prescribing in England: a longitudinal study. BJGP Open 2020; 4:bjgpopen20X101052. [PMID: 32665235 PMCID: PMC7465585 DOI: 10.3399/bjgpopen20x101052] [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: 02/03/2020] [Accepted: 02/10/2020] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND In 2017, approximately 73% of antibiotics in England were prescribed from primary care practices. It has been estimated that 9%-23% of antibiotic prescriptions between 2013 and 2015 were inappropriate. Reducing antibiotic prescribing in primary care was included as one of the national priorities in a financial incentive scheme in 2015-2016. AIM To investigate whether the effects of the Quality Premium (QP), which provided performance-related financial incentives to clinical commissioning groups (CCGs), could be explained by practice characteristics that contribute to variations in antibiotic prescribing. DESIGN & SETTING Longitudinal monthly prescribing data were analysed for 6251 primary care practices in England from April 2014 to March 2016. METHOD Linear generalised estimating equations models were fitted, examining the effect of the 2015-2016 QP on the number of antibiotic items per specific therapeutic group age-sex related prescribing unit (STAR-PU) prescribed, adjusting for seasonality and months since implementation. Consistency of effects after further adjustment for variations in practice characteristics were also examined, including practice workforce, comorbidities prevalence, prescribing rates of non-antibiotic drugs, and deprivation. RESULTS Antibiotics prescribed in primary care practices in England reduced by -0.172 items per STAR-PU (95% confidence interval [CI] = -0.180 to -0.171) after 2015-2016 QP implementation, with slight increases in the months following April 2015 (+0.014 items per STAR-PU; 95% CI = +0.013 to +0.014). Adjusting the model for practice characteristics, the immediate and month-on-month effects following implementation remained consistent, with slight attenuation in immediate reduction from -0.172 to -0.166 items per STAR-PU. In subgroup analysis, the QP effect was significantly greater among the top 20% prescribing practices (interaction p<0.001). Practices with low workforce and those with higher diabetes prevalence had greater reductions in prescribing following 2015-2016 QP compared with other practices (interaction p<0.001). CONCLUSION In high-prescribing practices, those with low workforce and high diabetes prevalence had more reduction following the QP compared with other practices, highlighting the need for targeted support of these practices and appropriate resourcing of primary care.
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Affiliation(s)
- Philip Emeka Anyanwu
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Koen Pouwels
- Nuffield Department of Population Health, Health Economics Research Centre, University of Oxford, Oxford, UK
| | - Anne Walker
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- National Institute for Health Research (NIHR) Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
| | - Michael Moore
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, UK
| | - Azeem Majeed
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Benedict W J Hayhoe
- Primary Care and Public Health, Imperial College London School of Public Health, London, UK
| | - Sarah Tonkin-Crine
- National Institute for Health Research (NIHR) Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Aleksandra Borek
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Susan Hopkins
- Healthcare-Associated Infection and Antimicrobial Resistance Department, National Infection Service, Public Health England, London, UK
- Directorate of Infection, Royal Free London NHS Foundation Trust, London, UK
- Department of Infectious Disease, Imperial College London, London, UK
| | - Monsey Mcleod
- Pharmacy Department, Centre for Medication Safety and Service Quality, Imperial College London, London, UK
- NIHR Patient Safety Translational Research Centre, Imperial College London, London, UK
- NIHR Health Protection Research Unit in Healthcare-Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
| | - Céire Costelloe
- Department of Primary Care and Public Health, Imperial College London, London, UK
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Li H, Gong Y, Han J, Zhang S, Chen S, Xu X, Lu Z, Yin X. Interrupted Time-Series Analysis to Evaluate the Impact of a National Antimicrobial Stewardship Campaign on Antibiotic Prescribing: A Typical Practice in China's Primary Care. Clin Infect Dis 2020; 73:e4463-e4471. [PMID: 32649745 DOI: 10.1093/cid/ciaa962] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 07/07/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND After implementing the 2011 national antimicrobial stewardship campaign, few studies focused on evaluating its effect in China's primary care facilities. METHODS We randomly selected 11 community health centers in Shenzhen, China, and collected all outpatient prescriptions of these centers from 2010-2015. To evaluate the impact of local interventions on antibiotic prescribing, we used a segmented regression model of interrupted time series to analyze seven outcomes, i.e., percentage of prescriptions with antibiotics, and percentages of prescriptions with broad-spectrum antibiotics, with parenteral antibiotics, and with two or more antibiotics in all prescriptions or antibiotics-containing prescriptions. RESULTS Overall, 1 482 223 outpatient prescriptions were obtained. The intervention was associated with a significant immediate change (-5.2%, P=.04) and change in slope (-3.1% per month, P<.01) for the percentage of prescriptions with antibiotics, and its relative cumulative effect at the end of the study was -74.0% (95% confidence interval, -79.0% to -69.1%). After the intervention, the percentage of prescriptions with broad-spectrum, and with parenteral antibiotics decreased dramatically by 36.7% and 77.3%, respectively, but their percentages in antibiotic-containing prescriptions decreased insignificantly. Percentage of prescriptions with two or more antibiotics in all prescriptions or antibiotics-containing prescriptions only showed immediate changes, but significant changes in slope were not observed. CONCLUSIONS A typical practice in Shenzhen, China, showed that strict enforcement of antimicrobial stewardship campaign could effectively reduce antibiotic prescribing in primary care with a stable long-term effect. However, prescribing of broad-spectrum and parenteral antibiotics was still prevalent. More targeted interventions are required to promote appropriate antibiotic use.
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Affiliation(s)
- Hui Li
- Department of Social Medicine and Health Management, School of Public Health, Huazhong University of Science and Technology, Wuhan, P. R. China
| | - Yanhong Gong
- Department of Social Medicine and Health Management, School of Public Health, Huazhong University of Science and Technology, Wuhan, P. R. China
| | - Jing Han
- Department of Community Health Management, Baoan District Central Hospital, Shenzhen, P. R. China
| | - Shengchao Zhang
- Department of Community Health Management, Baoan District Central Hospital, Shenzhen, P. R. China
| | - Shanquan Chen
- The School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Xing Xu
- German Cancer Research Center (DKFZ), Heidelberg University, Heidelberg, Germany
| | - Zuxun Lu
- Department of Social Medicine and Health Management, School of Public Health, Huazhong University of Science and Technology, Wuhan, P. R. China
| | - Xiaoxv Yin
- Department of Social Medicine and Health Management, School of Public Health, Huazhong University of Science and Technology, Wuhan, P. R. China
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Avent ML, Cosgrove SE, Price-Haywood EG, van Driel ML. Antimicrobial stewardship in the primary care setting: from dream to reality? BMC FAMILY PRACTICE 2020; 21:134. [PMID: 32641063 PMCID: PMC7346425 DOI: 10.1186/s12875-020-01191-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 06/15/2020] [Indexed: 12/03/2022]
Abstract
BACKGROUND Clinicians who work in primary care are potentially the most influential healthcare professionals to address the problem of antibiotic resistance because this is where most antibiotics are prescribed. Despite a number of evidence based interventions targeting the management of community infections, the inappropriate antibiotic prescribing rates remain high. DISCUSSION The question is how can appropriate prescribing of antibiotics through the use of Antimicrobial Stewardship (AMS) programs be successfully implemented in primary care. We discuss that a top-down approach utilising a combination of strategies to ensure the sustainable implementation and uptake of AMS interventions in the community is necessary to support clinicians and ensure a robust implementation of AMS in primary care. Specifically, we recommend a national accreditation standard linked to the framework of Core Elements of Outpatient Antibiotic Stewardship, supported by resources to fund the implementation of AMS interventions that are connected to quality improvement initiatives. This article debates how this can be achieved. The paper highlights that in order to support the sustainable uptake of AMS programs in primary care, an approach similar to the hospital and post-acute care settings needs to be adopted, utilising a combination of behavioural and regulatory processes supported by sustainable funding. Without these strategies the problem of inappropriate antibiotic prescribing will not be adequately addressed in the community and the successful implementation and uptake of AMS programs will remain a dream.
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Affiliation(s)
- M L Avent
- Statewide Antimicrobial Stewardship Program, Queensland Health, Brisbane, Australia.
- UQ Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, Australia.
| | - S E Cosgrove
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - E G Price-Haywood
- Ochsner Health System, Center for Outcomes and Health Services Research, New Orleans, Louisiana, USA
- Ochnser Clinical School, The University of Queensland, New Orleans, Louisiana, USA
| | - M L van Driel
- Primary Care Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, Australia
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Improving Antimicrobial Use in Adult Outpatient Clinics: the New Frontier for Antimicrobial Stewardship Programs. Curr Infect Dis Rep 2020. [DOI: 10.1007/s11908-020-00722-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Gulliford MC, Sun X, Charlton J, Winter JR, Bunce C, Boiko O, Fox R, Little P, Moore M, Hay AD, Ashworth M. Serious bacterial infections and antibiotic prescribing in primary care: cohort study using electronic health records in the UK. BMJ Open 2020; 10:e036975. [PMID: 32114481 PMCID: PMC7050314 DOI: 10.1136/bmjopen-2020-036975] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 01/31/2020] [Accepted: 02/03/2020] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE This study evaluated whether serious bacterial infections are more frequent at family practices with lower antibiotic prescribing rates. DESIGN Cohort study. SETTING 706 UK family practices in the Clinical Practice Research Datalink from 2002 to 2017. PARTICIPANTS 10.1 million registered patients with 69.3 million patient-years' follow-up. EXPOSURES All antibiotic prescriptions, subgroups of acute and repeat antibiotic prescriptions, and proportion of antibiotic prescriptions associated with specific-coded indications. MAIN OUTCOME MEASURES First episodes of serious bacterial infections. Poisson models were fitted adjusting for age group, gender, comorbidity, deprivation, region and calendar year, with random intercepts representing family practice-specific estimates. RESULTS The age-standardised antibiotic prescribing rate per 1000 patient-years increased from 2002 (male 423; female 621) to 2012 (male 530; female 842) before declining to 2017 (male 449; female 753). The median family practice had an antibiotic prescribing rate of 648 per 1000 patient-years with 95% range for different practices of 430-1038 antibiotic prescriptions per 1000 patient-years. Specific coded indications were recorded for 58% of antibiotic prescriptions at the median family practice, the 95% range at different family practices was from 10% to 75%. There were 139 759 first episodes of serious bacterial infection. After adjusting for covariates and the proportion of coded consultations, there was no evidence that serious bacterial infections were lower at family practices with higher total antibiotic prescribing. The adjusted rate ratio for 20% higher total antibiotic prescribing was 1.03, (95% CI 1.00 to 1.06, p=0.074). CONCLUSIONS We did not find population-level evidence that family practices with lower total antibiotic prescribing might have more frequent occurrence of serious bacterial infections overall. Improving the recording of infection episodes has potential to inform better antimicrobial stewardship in primary care.
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Affiliation(s)
- Martin C Gulliford
- School of Population Health and Environmental Sciences, King's College London, London, UK
- NIHR Biomedical Research Centre at Guy's and St Thomas' Hospitals London, GreatMaze Pond, London, UK
| | - Xiaohui Sun
- School of Population Health and Environmental Sciences, King's College London, London, UK
| | - Judith Charlton
- School of Population Health and Environmental Sciences, King's College London, London, UK
| | - Joanne R Winter
- School of Population Health and Environmental Sciences, King's College London, London, UK
| | - Catey Bunce
- School of Population Health and Environmental Sciences, King's College London, London, UK
- NIHR Biomedical Research Centre at Guy's and St Thomas' Hospitals London, GreatMaze Pond, London, UK
| | - Olga Boiko
- School of Population Health and Environmental Sciences, King's College London, London, UK
| | - Robin Fox
- The Health Centre, Coker Close, Bicester, UK
| | - Paul Little
- Primary Care Research Group, University of Southampton, Southampton, UK
| | - Michael Moore
- Primary Care Research Group, University of Southampton, Southampton, UK
| | - Alastair D Hay
- Centre for Academic Primary Care, Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, UK
| | - Mark Ashworth
- School of Population Health and Environmental Sciences, King's College London, London, UK
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Anyanwu PE, Borek AJ, Tonkin-Crine S, Beech E, Costelloe C. Conceptualising the Integration of Strategies by Clinical Commissioning Groups in England towards the Antibiotic Prescribing Targets for the Quality Premium Financial Incentive Scheme: A Short Report. Antibiotics (Basel) 2020; 9:antibiotics9020044. [PMID: 31979209 PMCID: PMC7167865 DOI: 10.3390/antibiotics9020044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 01/06/2020] [Accepted: 01/21/2020] [Indexed: 12/02/2022] Open
Abstract
Background: In order to tackle the public health threat of antimicrobial resistance, improvement in antibiotic prescribing in primary care was included as one of the priorities of the Quality Premium (QP) financial incentive scheme for Clinical Commissioning Groups (CCGs) in England. This paper briefly reports the outcome of a workshop exploring the experiences of antimicrobial stewardship (AMS) leads within CCGs in selecting and adopting strategies to help achieve the QP antibiotic targets. Methods: We conducted a thematic analysis of the notes on discussions and observations from the workshop to identify key themes. Results: Practice visits, needs assessment, peer feedback and audits were identified as strategies integrated in increasing engagement with practices towards the QP antibiotic targets. The conceptual model developed by AMS leads demonstrated possible pathways for the impact of the QP on antibiotic prescribing. Participants raised a concern that the constant targeting of high prescribing practices for AMS interventions might lead to disengagement by these practices. Most of the participants suggested that the effect of the QP might be less about the financial incentive and more about having national targets and guidelines that promote antibiotic prudency. Conclusions: Our results suggest that national targets, rather than financial incentives are key for engaging stakeholders in quality improvement in antibiotic prescribing.
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Affiliation(s)
- Philip Emeka Anyanwu
- Global Digital Health Unit, Department of Primary Care and Public Health, Imperial College London, London W6 8RP, UK;
- Correspondence:
| | - Aleksandra J. Borek
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford OX2 6GG, UK; (A.J.B.); (S.T.-C.)
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford OX2 6GG, UK; (A.J.B.); (S.T.-C.)
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford OX2 6GG, UK
| | - Elizabeth Beech
- NHS Bath and North East Somerset Clinical Commissioning Group, NHS Improvements London, London BA2 5RP, UK;
| | - Céire Costelloe
- Global Digital Health Unit, Department of Primary Care and Public Health, Imperial College London, London W6 8RP, UK;
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Temporal trends of inpatient C. difficile infections within the Veterans Health Administration hospitals: An analysis of the effect of molecular testing, time to testing, and mandatory reporting. Infect Control Hosp Epidemiol 2019; 41:44-51. [PMID: 31708000 DOI: 10.1017/ice.2019.281] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Clostridium difficile infection (CDI) is a reportable hospital metric associated with significant healthcare expenditures. The epidemiology of CDI is pivotal to the implementation of preventative measures. OBJECTIVE To portray temporal CDI trends in Veterans Health Administration (VA) hospitals. DESIGN A retrospective analysis of veterans who had stool testing for C. difficile. SETTING VA acute-care hospitals within the continental United States. METHODS Data were mined from the VA's Corporate Data Warehouse. CDI is reported per 10,000 patient days. RESULTS From 2006 to 2016, 472,346 patients had C. difficile testing. Overall, decreases in incidence of total CDI (16.81 to 13.66) and hospital-onset healthcare facility-associated (HO-HCFA) CDI (10.87 to 6.41) were observed. Temporal increases in the incidence of total and HO-HCFA CDI were associated with the increased use of molecular testing (P < .0001). Decreased use of fluoroquinolones (P < .0001), clindamycin (P = .0006), and third-generation cephalosporins (P = .0002) correlated with decreased rates of CDI, but VA mandatory reporting did not influence CDI rates (P = .24). The overall crude 30-day mortality of patients with CDI decreased from 2.17 deaths per 10,000 patient days in 2006 to 1.41 in 2016. The frequency of International Classification of Disease, Ninth/Tenth Revision (ICD-9/10) discharge diagnosis for CDI was 73.3%. CONCLUSION Molecular testing was associated with increased incidence of CDI. Controlling CDI is likely multifactorial. Although the VA initiative to report cases of hospital-acquired CDI was not significant in our model, the advent of stewardship programs throughout the VA and reductions in the use of third-generation cephalosporins, fluoroquinolones, and clindamycin were significantly associated with reduced rates of CDI.
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Biro A, Elek P. The effect of primary care availability on antibiotic consumption in Hungary: a population based panel study using unfilled general practices. BMJ Open 2019; 9:e028233. [PMID: 31519670 PMCID: PMC6747682 DOI: 10.1136/bmjopen-2018-028233] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 07/31/2019] [Accepted: 08/14/2019] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE We analyse the effect of primary care availability on antibiotic consumption and on the quality of antibiotic prescribing behaviour. DESIGN Retrospective panel design, secondary analysis of settlement-level administrative panel data (n=2320 settlements, T=72 months). PARTICIPANTS AND SETTING We analyse antibiotic consumption of the population of villages in Hungary, over years 2010 to 2015. We exploit the geographical and time variation in unfilled (mainly single-handed) general practices as a source of exogenous variation in the availability of primary care. We control for socioeconomic characteristics and settlement fixed effects in a panel regression framework. OUTCOME MEASURES Antibiotic expenditures and days of therapy (DOT); consumption of narrow-spectrum and broad-spectrum antibiotics; consumption of Access, Watch and Reserve antibiotics according to the AWaRe categorisation; number of visits to the general practitioner (GP). RESULTS If the general practice of a village becomes unfilled, the number of GP visits decreases on average by 9.3% (95% CI 5.6% to 12.9%), antibiotics DOT decrease on average by 3.2% (95% CI 1.0% to 5.4%) and expenditures on antibiotics decrease on average by 2.5% (95% CI 0.3% to 4.7%). The negative effect on antibiotic consumption is stronger in settlements where secondary care is less available, and where antibiotics were previously overprescribed. The quality of prescribing behaviour measured by the relative changes in the narrow-spectrum vs broad-spectrum as well as the Access versus Watch and Reserve antibiotics deteriorates significantly as a consequence of worse primary care availability. CONCLUSIONS Limited availability of primary care reduces the consumption of antibiotics and at the same time impairs the quality of prescriptions through a decrease of the number of doctor-patient encounters.
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Affiliation(s)
- Aniko Biro
- Institute of Economics at the Centre for Economic and Regional Studies of the Hungarian Academy of Sciences, Budapest, Hungary
| | - Peter Elek
- Institute of Economics at the Centre for Economic and Regional Studies of the Hungarian Academy of Sciences, Budapest, Hungary
- Eötvös Loránd University, Budapest, Hungary
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Gharbi M, Drysdale JH, Lishman H, Goudie R, Molokhia M, Johnson AP, Holmes AH, Aylin P. Antibiotic management of urinary tract infection in elderly patients in primary care and its association with bloodstream infections and all cause mortality: population based cohort study. BMJ 2019; 364:l525. [PMID: 30814048 PMCID: PMC6391656 DOI: 10.1136/bmj.l525] [Citation(s) in RCA: 107] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To evaluate the association between antibiotic treatment for urinary tract infection (UTI) and severe adverse outcomes in elderly patients in primary care. DESIGN Retrospective population based cohort study. SETTING Clinical Practice Research Datalink (2007-15) primary care records linked to hospital episode statistics and death records in England. PARTICIPANTS 157 264 adults aged 65 years or older presenting to a general practitioner with at least one diagnosis of suspected or confirmed lower UTI from November 2007 to May 2015. MAIN OUTCOME MEASURES Bloodstream infection, hospital admission, and all cause mortality within 60 days after the index UTI diagnosis. RESULTS Among 312 896 UTI episodes (157 264 unique patients), 7.2% (n=22 534) did not have a record of antibiotics being prescribed and 6.2% (n=19 292) showed a delay in antibiotic prescribing. 1539 episodes of bloodstream infection (0.5%) were recorded within 60 days after the initial UTI. The rate of bloodstream infection was significantly higher among those patients not prescribed an antibiotic (2.9%; n=647) and those recorded as revisiting the general practitioner within seven days of the initial consultation for an antibiotic prescription compared with those given a prescription for an antibiotic at the initial consultation (2.2% v 0.2%; P=0.001). After adjustment for covariates, patients were significantly more likely to experience a bloodstream infection in the deferred antibiotics group (adjusted odds ratio 7.12, 95% confidence interval 6.22 to 8.14) and no antibiotics group (8.08, 7.12 to 9.16) compared with the immediate antibiotics group. The number needed to harm (NNH) for occurrence of bloodstream infection was lower (greater risk) for the no antibiotics group (NNH=37) than for the deferred antibiotics group (NNH=51) compared with the immediate antibiotics group. The rate of hospital admissions was about double among cases with no antibiotics (27.0%) and deferred antibiotics (26.8%) compared with those prescribed immediate antibiotics (14.8%; P=0.001). The risk of all cause mortality was significantly higher with deferred antibiotics and no antibiotics than with immediate antibiotics at any time during the 60 days follow-up (adjusted hazard ratio 1.16, 95% confidence interval 1.06 to 1.27 and 2.18, 2.04 to 2.33, respectively). Men older than 85 years were particularly at risk for both bloodstream infection and 60 day all cause mortality. CONCLUSIONS In elderly patients with a diagnosis of UTI in primary care, no antibiotics and deferred antibiotics were associated with a significant increase in bloodstream infection and all cause mortality compared with immediate antibiotics. In the context of an increase of Escherichia coli bloodstream infections in England, early initiation of recommended first line antibiotics for UTI in the older population is advocated.
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Affiliation(s)
- Myriam Gharbi
- NIHR Health Protection Research Unit, Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | | | - Hannah Lishman
- NIHR Health Protection Research Unit, Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Rosalind Goudie
- NIHR Health Protection Research Unit, Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
- Department of Primary Care and Public Health, Imperial College London, London, UK
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Mariam Molokhia
- Department of Primary Care and Public Health Sciences, King's College, London, UK
| | - Alan P Johnson
- NIHR Health Protection Research Unit, Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
- Healthcare-Associated Infections and Antimicrobial Resistance Division, National Infection Service, Public Health England, London, UK
| | - Alison H Holmes
- NIHR Health Protection Research Unit, Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
| | - Paul Aylin
- NIHR Health Protection Research Unit, Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
- Department of Primary Care and Public Health, Imperial College London, London, UK
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