Defining the appropriateness and inappropriateness of antibiotic prescribing in primary care

Appropriateness of intended antibiotic prescribing using clinical case vignettes in primary care, and related factors

BACKGROUND

Factors associated with the appropriateness of antibiotic prescribing in primary care have been poorly explored. In particular, the impact of computerised decision-support systems (CDSS) remains unknown.

OBJECTIVES

We aim at investigating the uptake of CDSS and its association with physician characteristics and professional activity.

METHODS

Since May 2022, users of a CDSS for antibiotic prescribing in primary care in France have been invited, when registering, to complete three case vignettes assessing clinical situations frequently encountered in general practice and identified as at risk of antibiotic misuse. Appropriateness of antibiotic prescribing was defined as the rate of answers in line with the current guidelines, computed by individuals and by specific questions. Physician's characteristics associated with individual appropriate antibiotic prescribing (< 50%, 50-75% and > 75% appropriateness) were identified by multivariate ordinal logistic regression.

RESULTS

In June 2023, 60,067 physicians had registered on the CDSS. Among the 13,851 physicians who answered all case vignettes, the median individual appropriateness level of antibiotic prescribing was 77.8% [Interquartile range, 66.7%-88.9%], and was < 50% for 1,353 physicians (10%). In the multivariate analysis, physicians' characteristics associated with appropriateness were prior use of the CDSS (OR = 1.71, 95% CI 1.56-1.87), being a general practitioner vs. other specialist (OR = 1.34, 95% CI 1.20-1.49), working in primary care (OR = 1.14, 95% CI 1.02-1.27), mentoring students (OR = 1.12, 95% CI 1.04-1.21) age (OR = 0.69 per 10 years increase, 95% CI 0.67-0.71).

CONCLUSION

Individual appropriateness for antibiotic prescribing was high among CDSS users, with a higher rate in young general practitioners, previously using the system. CDSS could improve antibiotic prescribing in primary care.

Temporal patterns of antibiotic prescribing for sore throat, otitis media, and sinusitis: a longitudinal study of general practitioner registrars

BACKGROUND

Antibiotics provide minimal benefit for sore throat, otitis media, and sinusitis. Antibiotic stewardship, with reduced prescribing, is required to address antibiotic resistance. As most antibiotic prescribing occurs in general practice and prescribing habits develop early, general practitioner (GP) trainees (registrars) are important for effective antibiotic stewardship.

OBJECTIVES

To establish temporal trends in Australian registrars' antibiotic prescribing for acute sore throat, acute otitis media, and acute sinusitis.

DESIGN

A longitudinal analysis of data from the Registrar Clinical Encounters in Training (ReCEnT) study from 2010 to 2019.

PARTICIPANTS

ReCEnT is an ongoing cohort study of registrars' in-consultation experiences and clinical behaviours. Pre-2016, 5 of 17 Australian training regions participated. From 2016, 3 of 9 regions (42% of Australian registrars) participate.

MAIN MEASURES

The outcome was prescription of an antibiotic for a new acute problem/diagnosis of sore throat, otitis media, or sinusitis. The study factor was year (2010-2019).

KEY RESULTS

Antibiotics were prescribed in 66% of sore throat diagnoses, 81% of otitis media, and in 72% of sinusitis. Prescribing frequencies decreased between 2010 and 2019 by 16% for sore throat (from 76% to 60%) by 11% for otitis media (from 88% to 77%) and by 18% for sinusitis (from 84% to 66%). In multivariable analyses, "Year" was associated with reduced prescribing for sore throat (OR 0.89; 95%CI 0.86-0.92; p < 0.001), otitis media (OR 0.90; 95%CI 0.86-0.94; p < 0.001), and sinusitis (OR 0.90; 95%CI 0.86, 0.94; p < 0.001).

CONCLUSIONS

Registrars' prescribing rates for sore throat, otitis media, and sinusitis significantly decreased during the period 2010-2019. However, educational (and other) interventions to further reduce prescribing are warranted.

'When all you have is a hammer, everything has to be a nail': Managing diagnostic uncertainty in urinary tract infection

Diagnosis of urinary tract infections (UTI) is a routine part of medical work and yet is well recognised to be an area of high clinical uncertainty. Meanwhile, diagnosis of UTI is becoming increasingly important to policymakers globally due to concerns about antibiotic over-prescription. Drawing on Mol's concept of ontological multiplicity in clinical work, I explore how diagnostic uncertainty is co-ordinated into certainty by a UK national diagnostic algorithm for UTI. The diagnosis of UTI is produced or withheld as a post hoc rationalisation of a prior decision whether to prescribe antibiotics or not. Work in the sociology of diagnosis has already noted that diagnostic steps are often re-ordered by health-care professionals taking diverse actions in the best interest of their patients. This article contributes an argument that ordering diagnostic work around antimicrobial stewardship agendas has the effect of narrowing possible actions. Exploring the consequences and effects of doing diagnosis in this way for different groups, I argue that a greater creativity about what could be done to care for painful bladders could be found in a return to more clinical ways of working.

Assessing the Feasibility of a Two-Cohort Design to Assess the Potential of Homeopathic Medicinal Products to Reduce Antimicrobial Resistance in Turkeys (The HOMAMR Project)-Study Protocol

BACKGROUND

 Antimicrobial resistance (AMR) is a serious public health concern worldwide. The European Union requires a reduction in the use of antibiotics by 50% by 2030, with separate regulations on organic production that give preference to homeopathy and phytotherapy in organic farms before the use of conventional medicines (including antibiotics). We have therefore designed a two-phased project whose overarching aim is to investigate the potential role of homeopathic medicinal products (HMPs) in combating AMR in turkeys (the HOMAMR project): a two-cohort feasibility study using turkey-farm data that have been collected and analyzed retrospectively, followed by a prospective two-cohort study in turkey farms that would examine the impact of HMPs on changing antibiotic use.

OBJECTIVE

 The objective of this paper is to describe the protocol for the first phase of HOMAMR, which is a study under field conditions to assess the feasibility of collecting data retrospectively about turkeys that have been managed conventionally only or with HMPs.

METHODS

 Surveys performed on farms in Germany and Austria, including interviews with consenting farmers, will determine the feasibility of comparing retrospectively gathered data on antibiotic use and performance/production data in two cohorts of turkeys: (1) homeopathic treatment with conventional care (antibiotics) added if necessary or (2) conventional care (antibiotics) only. Co-primary outcomes to be studied are the amount of antimicrobial use and production period-related mortality. In addition, other production/performance parameters will be compared between the two treated cohorts.

CONCLUSION

 To our knowledge, this is the first feasibility study on the treatment of turkeys using homeopathy, and whose retrospectively obtained data will inform a prospective study that would examine the impact of HMPs on antibiotic use in commercial turkey raising, fattening and breeding production.

Differences in antibiotic use between COPD and non-COPD residents based on the health information system

OBJECTIVES

To compare the differences in antibiotic use between COPD and non-COPD residents, and to explore the effect of COPD on antibiotic use.

METHODS

Participants aged 40 years old or over from the Songjiang Adult Cohort were included. Information on prescription and baseline survey was collected based on the health information system. A logit-negative binomial Hurdle model was used to explore correlations between COPD and percentage of antibiotic use and average rate of antibiotic prescribing of different types of antibiotic. Multinomial logistic regression was used to assess the association between COPD and antimicrobial combination therapy and routes of administration.

RESULTS

A total of 34576 individuals were included and 1594 (4.6%) were COPD patients. During the 6 years' follow-up, the percentage of antibiotic use for COPD patients was 98.4%, which was 7.88 (95%CI: 5.24-11.85) times of that for non-COPD patients after adjusting for potential confounders. The prescribing rate was 3220 prescriptions (95%CI: 3063.6-3385.2) per 1000 person-years for COPD patients, which was 1.96 (95%CI: 1.87-2.06) times of that for non-COPD patients. Other beta-lactam antibacterials, Macrolides, lincosamides and streptogramins, and quinolone antibacterials were the most commonly used types of antibiotic. Except for aminoglycoside antibacterials, both percentage of antibiotic use and rate of antibiotic prescription were increased in COPD patients. COPD patients were more likely to be prescribed a maximum of two antibiotics (OR=1.34, 95%CI: 1.20-1.50); and were more likely to use antibiotics intravenously (OR=2.77, 95%CI: 2.47-3.11).

CONCLUSION

COPD patients were more likely to have increased antibiotic use in a large-scale population-based adult cohort, suggesting COPD patients are a high-priority group for the management of antibiotic use in communities.

Within-episode repeat antibiotic prescriptions in patients with respiratory tract infections: A population-based cohort study

BACKGROUND

Antimicrobial stewardship interventions mainly focus on initial antibiotic prescriptions, with few considering within-episode repeat prescriptions. We aimed to describe the magnitude, type and determinants of within-episode repeat antibiotic prescriptions in patients presenting to primary care with respiratory tract infections (RTIs).

METHODS

We conducted a population-based cohort study among 530 sampled English general practices within the Clinical Practice Research Datalink (CPRD). All individuals with a primary care RTI consultation for which an antibiotic was prescribed between March 2018 and February 2022. Main outcome measurement was repeat antibiotic prescriptions within 28 days of a RTI visit stratified by age (children vs. adults) and RTI type (lower vs. upper RTI). Multivariable logistic regression and principal components analyses were used to identify risk factors and patient clusters at risk for within-episode repeat prescriptions.

FINDINGS

905,964 RTI episodes with at least one antibiotic prescription were identified. In adults, 19.9% (95% CI 19.3-20.5%) had at least one within-episode repeat prescription for a lower RTI, compared to 10.5% (95% CI 10.3-10.8%) for an upper RTI. In children, this was around 10% irrespective of RTI type. The majority of repeat prescriptions occurred a median of 10 days after the initial prescription and was the same antibiotic class in 48.3% of cases. Frequent RTI related GP visits and prior within-RTI-episode repeat antibiotic prescriptions were main factors associated with repeat prescriptions in both adults and children irrespective of RTI type. Young (<2 years) and older (65+) age were associated with repeat prescriptions. Among those aged 2-64 years, allergic rhinitis, COPD and oral corticosteroids were associated with repeat prescriptions.

INTERPRETATIONS

Repeat within-episode antibiotic use accounts for a significant proportion of all antibiotics prescribed for RTIs, with same class antibiotics unlikely to confer clinical benefit and is therefore a prime target for future antimicrobial stewardship interventions.

Assessing the Appropriateness of Antimicrobial Prescribing in the Community Setting: A Scoping Review

Background

This scoping review examined the concept and scope of appropriateness of antimicrobial prescribing in the community setting and how it has been measured.

Methods

Utilizing the Joanna Briggs Institute's methodology, we appraised peer-reviewed articles and unpublished studies, focusing on the US, UK, Canada, and Australia, with no limit to date.

Results

Four basic components of antimicrobial prescribing to be evaluated during assessment of antimicrobial appropriateness in the community setting were identified: diagnosis for infection or indication for antimicrobial therapy, choice of antimicrobial therapy, dosing, and duration of therapy. The benchmark for definition of appropriateness is crucial in assessing antimicrobial prescribing appropriateness. The use of recommended guidelines as a benchmark is the standard for appropriate antimicrobial therapy, and when necessary, susceptibility testing should be explored.

Conclusions

Studies evaluating the appropriateness of antimicrobial prescribing should assess these components of antimicrobial prescribing, and this should be clearly stated in the aim and objectives of the study.

Appropriateness of acute-care antibiotic prescriptions for community-acquired infections and surgical antibiotic prophylaxis in England: analysis of 2016 national point prevalence survey data

BACKGROUND

Estimates of inappropriate prescribing can highlight key target areas for antimicrobial stewardship (AMS) and inform national targets.

OBJECTIVES

To (1) define and (2) produce estimates of inappropriate antibiotic prescribing levels within acute hospital trusts in England.

METHODS

The 2016 national Healthcare-Associated Infections (HAI), Antimicrobial Use (AMU) and AMS point prevalence survey (PPS) was used to derive estimates of inappropriate prescribing, focusing on the four most reported community-acquired antibiotic indications (CAIs) in the PPS and surgical prophylaxis. Definitions of appropriate antibiotic therapy for each indication were developed through the compilation of national treatment guidelines. A Likert-scale system of appropriateness coding was validated and refined through a two-stage expert review process.

RESULTS

Antimicrobial usage prevalence data were collected for 25,741 individual antibiotic prescriptions, representing 17,884 patients and 213 hospitals in England. 30.4% of prescriptions for the four CAIs of interest were estimated to be inappropriate (2054 prescriptions). The highest percentage of inappropriate prescribing occurred in uncomplicated cystitis prescriptions (62.5%), followed by bronchitis (48%). For surgical prophylaxis, 30.8% of prescriptions were inappropriate in terms of dose number, and 21.3% in terms of excess prophylaxis duration.

CONCLUSIONS

The 2016 prevalence of inappropriate antibiotic prescribing in hospitals in England was approximated to be 30.4%; this establishes a baseline prevalence and provided indication of where AMS interventions should be prioritized. Our definitions appraised antibiotic choice, treatment duration and dose number (surgical prophylaxis only); however, they did not consider other aspects of appropriateness, such as combination therapy - this is an important area for future work.

Acute pharyngitis in children and adults: descriptive comparison of current recommendations from national and international guidelines and future perspectives

This study aims to provide a comparison of the current recommendations about the management of acute pharyngitis. A literature search was conducted from January 2009 to 2023. Documents reporting recommendations on the management of acute pharyngitis were included, pertinent data were extracted, and a descriptive comparison of the different recommendations was performed. The quality of guidelines was assessed through the AGREE II instrument. Nineteen guidelines were included, and an overall moderate quality was found. Three groups can be distinguished: one group supports the antibiotic treatment of group A β-hemolytic Streptococcus (GABHS) to prevent acute rheumatic fever (ARF); the second considers acute pharyngitis a self-resolving disease, recommending antibiotics only in selected cases; the third group recognizes a different strategy according to the ARF risk in each patient. An antibiotic course of 10 days is recommended if the prevention of ARF is the primary goal; conversely, some guidelines suggest a course of 5-7 days, assuming the symptomatic cure is the goal of treatment. Penicillin V and amoxicillin are the first-line options. In the case of penicillin allergy, first-generation cephalosporins are a suitable choice. In the case of beta-lactam allergy, clindamycin or macrolides could be considered according to local resistance rates.    Conclusion: Several divergencies in the management of acute pharyngitis were raised among guidelines (GLs) from different countries, both in the diagnostic and therapeutic approach, allowing the distinction of 3 different strategies. Since GABHS pharyngitis could affect the global burden of GABHS disease, it is advisable to define a shared strategy worldwide. It could be interesting to investigate the following issues further: cost-effectiveness analysis of diagnostic strategies in different healthcare systems; local genomic epidemiology of GABHS infection and its complications; the impact of antibiotic treatment of GABHS pharyngitis on its complications and invasive GABHS infections; the role of GABHS vaccines as a prophylactic measure. The related results could aid the development of future recommendations. What is Known: • GABHS disease spectrum ranges from superficial to invasive infections and toxin-mediated diseases. • GABHS accounts for about 25% of sore throat in children and its management is a matter of debate. What is New: • Three strategies can be distinguished among current GLs: antibiotic therapy to prevent ARF, antibiotics only in complicated cases, and a tailored strategy according to the individual ARF risk. • The impact of antibiotic treatment of GABHS pharyngitis on its sequelae still is the main point of divergence; further studies are needed to achieve a global shared strategy.

Do family medicine residents optimally prescribe antibiotics for common infectious conditions seen in a primary care setting?

Background

Antimicrobial resistance is a worldwide phenomenon that leads to a significant number of unnecessary deaths and costly hospital admissions. More than 90% of antibiotic use happens in the community and of this, family physicians account for two-thirds of these prescriptions. Our study aims to determine whether family medicine residents are optimally trained in antibiotic prescribing for common infectious conditions seen in a primary care setting.

Methods

This study is a secondary analysis of a prior study of antimicrobial stewardship in two urban primary care clinics in central Toronto, Ontario. A total of 1099 adult patient visits were included that involved family medicine resident trainees, seen between 2015 and 2016. The main outcome measures were resident antibiotic prescription rates for each condition and expert-recommended prescribing practices, the rate prescriptions were issued as delayed prescriptions, and the use of first-line recommended narrow-spectrum antibiotics.

Results

Compared to expert-recommended prescribing rates, family medicine residents overprescribed for uncomplicated upper respiratory tract infections (URI) (5.0% [95% CI 2.2% to 9.7%] versus 0% expert recommended) and sinusitis (44.2% [95% CI 32.8% to 55.9%] versus 11%-18% expert range), and under prescribed for pneumonia (53.5% [95% CI 37.7% to 68.8%] versus 100% expert range]). Prescribing rates were within expert recommended ranges for pharyngitis (28.6% [95% CI 16.6% to 43.3%]), bronchitis (3.6% [95% CI 0% to 18.4%]), and cystitis (79.4% [95% CI 70.6% to 86.6%]).

Conclusions

The antibiotic prescribing practices of family medicine residents during their training programs indicated overprescribing of antibiotics for some common infection presentations. Further study of antibiotic prescribing in primary care training programs across Canada is recommended to determine if future family physicians are learning appropriate antibiotic prescribing practices.

Impact of the COVID-19 pandemic on antimicrobial stewardship support for general practices in England: a qualitative interview study

BACKGROUND

In England, clinical commissioning group (CCG; now replaced by Integrated Care Systems [ICSs]) and primary care network (PCN) professionals support primary care prescribers to optimise antimicrobial stewardship (AMS).

AIM

To explore views and experiences of CCG and PCN staff in supporting AMS, and the impact of COVID-19 on this support.

DESIGN & SETTING

Qualitative interview study in primary care in England.

METHOD

Semi-structured interviews with staff from CCG and PCNs responsible for AMS were conducted at two timepoints via telephone. These were audio-recorded, transcribed, and analysed thematically.

RESULTS

Twenty-seven interviews were conducted with 14 participants (nine CCG, five PCN) in December 2020-January 2021 and February-May 2021. The study found that AMS support was (1) deprioritised in order to keep general practice operational and deliver COVID-19 vaccines; (2) disrupted as social distancing made it harder to build relationships, conduct routine AMS activities, and challenge prescribing decisions; and (3) adapted, with opportunities identified for greater use of technology and changing patient and public perceptions of viruses and self-care. It was also found that resources to support AMS were valued if they were both novel, to counter AMS 'fatigue', and sufficiently familiar to fit with existing and/or future AMS.

CONCLUSION

AMS needs to be reprioritised in general practice in the post-pandemic era and within the new ICSs in England. This should include interventions and strategies that combine novel elements with already familiar strategies to refresh prescribers' motivation and opportunities for AMS. Behaviour change interventions should be aimed at improving the culture and processes for how PCN pharmacists voice concerns about AMS to prescribers in general practice and take advantage of the changed patient and public perceptions of viruses and self-care.

The Real Practice Prescribing Antibiotics in Outpatients: A Failed Control Case Assessed through the Simulated Patient Method

The first level of medical care provides the largest number of consultations for the most frequent diseases at the community level, including acute pharyngitis (AP), acute diarrhoea (AD) and uncomplicated acute urinary tract infections (UAUTIs). The inappropriate use of antibiotics in these diseases represents a high risk for the generation of antimicrobial resistance (AMR) in bacteria causing community infections. To evaluate the patterns of medical prescription for these diseases in medical offices adjacent to pharmacies, we used an adult simulated patient (SP) method representing the three diseases, AP, AD and UAUTI. Each person played a role in one of the three diseases, with the signs and symptoms described in the national clinical practice guidelines (CPGs). Diagnostic accuracy and therapeutic management were assessed. Information from 280 consultations in the Mexico City area was obtained. For the 101 AP consultations, in 90 cases (89.1%), one or more antibiotics or antivirals were prescribed; for the 127 AD, in 104 cases (81.8%), one or more antiparasitic drugs or intestinal antiseptics were prescribed; for the scenarios involving UAUTIs in adult women, in 51 of 52 cases (98.1%) one antibiotic was prescribed. The antibiotic group with the highest prescription pattern for AP, AD and UAUTIs was aminopenicillins and benzylpenicillins [27/90 (30%)], co-trimoxazole [35/104 (27.6%)] and quinolones [38/51 (73.1%)], respectively. Our findings reveal the highly inappropriate use of antibiotics for AP and AD in a sector of the first level of health care, which could be a widespread phenomenon at the regional and national level and highlights the urgent need to update antibiotic prescriptions for UAUTIs according to local resistance patterns. Supervision of adherence to the CPGs is needed, as well as raising awareness about the rational use of antibiotics and the threat posed by AMR at the first level of care.

Evaluation of Implementation and Effectiveness of China's Antibiotic Stewardship in the First Affiliated Hospital of Sun Yat-sen University

Antibiotic stewardship has been prioritized by governments and health care organizations in recent years as antibiotic resistance is markedly increasing. A tertiary hospital in Guangzhou, China was chosen as a study example to undertake an implementation and effectiveness evaluation of China's antibiotic stewardship to improve and promote antimicrobial stewardship nationwide. The general surgery department of the study hospital was utilized to examine surgical site infection, and samples from across the hospital were used to identify bloodstream infection. Data was analyzed using descriptive analysis, the Mann-Kendall trend test, logit model and panel data model, and t-tests. In terms of prophylactic and therapeutic antibiotic rational use, respectively, we evaluated implementation conditions, the correlation between implementation and corresponding disease progress, and the cost-effectiveness of China's antibiotic stewardship. For perioperative prophylactic antibiotic use, antibiotic stewardship was found to have been well-implemented, cost-effective, and reduced the incidence of surgical site infection. However, concerning therapeutic use and antibiotic-resistant bacterial infection prophylaxis, the complexity of influencing factors and the contradiction between stewardship implementation and clinical demand needs to be further evaluated.

Determinants of the Empiric Use of Antibiotics by General Practitioners in South Africa: Observational, Analytic, Cross-Sectional Study

The overuse of antibiotics is the main driver of antimicrobial resistance (AMR). However, there has been limited surveillance data on AMR and antibiotic prescribing at a primary healthcare level in South Africa. An observational, analytic, cross-sectional study was undertaken to assess key factors associated with empiric antibiotic prescribing among private sector general practitioners (GPs) in the eThekwini district in South Africa, particularly for patients with acute respiratory infections (ARIs). A semi-structured web-based questionnaire was used between November 2020−March 2021. One hundred and sixteen (55.5%) responding GPs prescribed antibiotics empirically for patients with ARIs more than 70% of the time, primarily for symptom relief and the prevention of complications. GPs between the ages of 35−44 years (OR: 3.38; 95%CI: 1.15−9.88), >55 years (OR: 4.75; 95% CI 1.08−21) and in practice < 15 years (OR: 2.20; 95%CI: 1.08−4.51) were significantly more likely to prescribe antibiotics empirically. Three factors—workload/time pressures; diagnostic uncertainty, and the use of a formulary, were significantly associated with empiric prescribing. GPs with more experience and working alone were slightly less likely to prescribe antibiotics empirically. These findings indicate that a combination of environmental factors are important underlying contributors to the development of AMR. As a result, guide appropriate interventions using a health system approach, which includes pertinent prescribing indicators and targets.

Antibiotic prescribing amongst South African general practitioners in private practice: an analysis of a health insurance database

Objectives

To investigate the appropriateness of antibiotic prescribing among GPs in the private primary healthcare sector in South Africa.

Methods

An anonymized national database of claims for antibiotic prescriptions was obtained from a large medical insurer. Antibiotic prescriptions were categorized based on International Classification of Diseases (ICD-10) codes as ‘appropriate’, ‘potentially appropriate’ and ‘inappropriate’ using a classification scheme developed by Chua et al. (BMJ 2019; 364: k5092). Further assessments of antibiotic choice, dosage and duration of treatment were carried out to determine the appropriateness of ‘appropriate’ and ‘potentially appropriate’ prescriptions in comparison with treatment guidelines.

Results

In February 2018, 188 141 antibiotics were prescribed for 174 889 patients who consulted GPs in the private sector. Penicillins were the most frequently prescribed antibiotic class, making up 40.7% of all antibiotics prescribed. Amoxicillin/clavulanic acid was the most frequently prescribed antibiotic, making up 28.6% of all antibiotics prescribed. Diseases of the respiratory system generated the highest number of prescriptions, making up 46.1% of all diagnoses. Of all prescriptions, 8.8% were appropriate, 32.0% were potentially appropriate, 45.4% were inappropriate and 13.8% could not be assessed. Of the appropriately and potentially appropriately prescribed antibiotics, 30.8% were correct antibiotic selections. Of the correctly selected antibiotics for adults, 57.7% had correct doses. Of the antibiotics prescribed with correct doses for adults, 76.7% had correct dosage frequencies and durations of treatment.

Conclusions

The study revealed that antibiotics were frequently prescribed inappropriately by GPs in the private primary healthcare sector. There is thus a need to develop stewardship interventions in the sector.

Can primary care research be conducted more efficiently using routinely reported practice-level data: a cluster randomised controlled trial conducted in England?

OBJECTIVES

Conducting randomised controlled trials (RCTs) in primary care is challenging; recruiting patients during time-limited or remote consultations can increase selection bias and physical access to patients' notes is costly and time-consuming. We investigated barriers and facilitators to running a more efficient design.

DESIGN

An RCT aiming to reduce antibiotic prescribing among children presenting with acute cough and a respiratory tract infection (RTI) with a clinician-focused intervention, embedded at the practice level. By using aggregate level, routinely collected data for the coprimary outcomes, we removed the need to recruit individual participants.

SETTING

Primary care.

PARTICIPANTS

Baseline data from general practitioner practices and interviews with individuals from Clinical Research Networks (CRNs) in England who helped recruit practices and Clinical Commission Groups (CCGs) who collected outcome data.

INTERVENTION

The intervention included: (1) explicit elicitation of parental concerns, (2) a prognostic algorithm to identify children at low risk of hospitalisation and (3) provision of a printout for carers including safety-netting advice.

COPRIMARY OUTCOMES

For 0-9 years old-(1) Dispensing data for amoxicillin and macrolide antibiotics and (2) hospital admission rate for RTI.

RESULTS

We recruited 294 of the intended 310 practices (95%) representing 336 496 registered 0-9 years old (5% of all 0-9 years old children). Included practices were slightly larger, had slightly lower baseline prescribing rates and were located in more deprived areas reflecting the national distribution. Engagement with CCGs and their understanding of their role in this research was variable. Engagement with CRNs and installation of the intervention was straight-forward although the impact of updates to practice IT systems and lack of familiarity required extended support in some practices. Data on the coprimary outcomes were almost 100%.

CONCLUSIONS

The infrastructure for trials at the practice level using routinely collected data for primary outcomes is viable in England and should be promoted for primary care research where appropriate.

TRIAL REGISTRATION NUMBER

ISRCTN11405239.

Respiratory antibacterial prescribing in primary care and the COVID-19 pandemic in England, winter season 2020-21

BACKGROUND

Antibacterial prescribing for respiratory tract infections (RTIs) accounts for almost half of all prescribing in primary care. Nearly a quarter of antibacterial prescribing in primary care is estimated to be inappropriate, the greatest being for RTIs. The COVID-19 pandemic has changed the provision of healthcare services and impacted the levels of antibacterials prescribed.

OBJECTIVES

To describe the changes in community antibacterial prescribing for RTIs in winter 2020-21 in England.

METHODS

RTI antibacterial prescribing was measured in prescription items/1000 population for primary care from January 2014 and in DDDs/1000 population/day for the totality of RTI prescribing [combined with Accident & Emergency (A&E) in secondary care], from January 2016 to February 2021. Trends were assessed using negative binomial regression and seasonally adjusted interrupted time-series analysis.

RESULTS

Antibacterials prescribed for RTIs reduced by a further 12.4% per season compared with pre-COVID (P < 0.001). In winter 2020-21, RTI prescriptions almost halved compared with the previous winter in 2019-20 (P < 0.001). The trend observed for total RTI prescribing (primary care with A&E) was similar to that observed in the community alone.

CONCLUSIONS

During COVID-19, RTI prescribing reduced in the community and the expected rise in winter was not seen in 2020-21. We found no evidence that RTI prescribing shifted from primary care to A&E in secondary care. The most likely explanation is a decrease in RTIs and presentations to primary care associated with national prevention measures for COVID-19.

Antibiotics for treatment of sore throat in children and adults

BACKGROUND

Sore throat is a common reason for people to present for medical care and to be prescribed antibiotics. Overuse of antibiotics in primary medicine is a concern, hence it is important to establish their efficacy in treating sore throat and preventing secondary complications.  OBJECTIVES: To assess the effects of antibiotics for reducing symptoms of sore throat for child and adult patients.

SEARCH METHODS

We searched CENTRAL 2021, Issue 2, MEDLINE (January 1966 to April week 1, 2021), Embase (January 1990 to April 2021), and two trial registries (searched 6 April 2021).

SELECTION CRITERIA

Randomised controlled trials (RCTs) or quasi-RCTs of antibiotics versus control assessing typical sore throat symptoms or complications amongst children and adults seeking medical care for sore throat symptoms.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as recommended by Cochrane. Two review authors independently screened studies for inclusion and extracted data, resolving any differences in opinion by discussion. We contacted the trial authors from three studies for additional information. We used GRADE to assess the certainty of the evidence for the efficacy of antibiotics on our primary outcomes (sore throat at day three and one week) and secondary outcomes (fever and headache symptoms and incidence of acute rheumatic fever, acute glomerulonephritis, acute otitis media, acute sinusitis, and quinsy).

MAIN RESULTS

We included 29 trials with 15,337 cases of sore throat. The majority of included studies were conducted in the 1950s, during which time the rates of serious complications (especially acute rheumatic fever) were much higher than today. Although clinical antibiotic trials for sore throat and respiratory symptoms are still being conducted, it is unusual for them to include placebo or 'no treatment' control arms, which is a requirement for inclusion in the review. The age of participants ranged from younger than one year to older than 50 years, but most participants across all studies were adults. Although all studies recruited patients presenting with symptoms of sore throat, few of them distinguished between bacterial and viral aetiology. Bias may have been introduced through non-clarity in treatment allocation procedures and lack of blinding in some studies. Harms from antibiotics were poorly or inconsistently reported, and were thus not quantified for this review. 1. Symptoms Throat soreness and headache at day three were reduced by using antibiotics, although 82% of participants in the placebo or no treatment group were symptom-free by one week. The reduction in sore throat symptoms at day three (risk ratio (RR) 0.70, 95% confidence interval (CI) 0.60 to 0.80; 16 studies, 3730 participants; moderate-certainty evidence) was greater than at one week in absolute numbers (RR 0.50, 95% CI 0.34 to 0.75; 14 studies, 3083 participants; moderate-certainty evidence) due to many cases in both treatment groups having resolved by this time. The number needed to treat for an additional beneficial outcome (NNTB) to prevent one sore throat at day three was less than six; at week one it was 18. Compared with placebo or no treatment, antibiotics did not significantly reduce fever at day three (RR 0.75, 95% CI 0.53 to 1.07; 8 studies, 1443 participants; high-certainty evidence), but did reduce headache at day three (RR 0.49, 95% CI 0.34 to 0.70; 4 studies, 1020 participants; high-certainty evidence). 2. Suppurative complications Whilst the prevalence of suppurative complications was low, antibiotics reduced the incidence of acute otitis media within 14 days (Peto odds ratio (OR) 0.21, 95% CI 0.11 to 0.40; 10 studies, 3646 participants; high-certainty evidence) and quinsy within two months (Peto OR 0.16, 95% CI 0.07 to 0.35; 8 studies, 2433 participants; high-certainty evidence) compared to those receiving placebo or no treatment, but not acute sinusitis within 14 days (Peto OR 0.46, 95% CI 0.10 to 2.05; 8 studies, 2387 participants; high-certainty evidence). 3. Non-suppurative complications There were too few cases of acute glomerulonephritis to determine whether there was a protective effect of antibiotics compared with placebo against this complication (Peto OR 0.07, 95% CI 0.00 to 1.32; 10 studies, 5147 participants; low-certainty evidence). Antibiotics reduced acute rheumatic fever within two months when compared to the control group (Peto OR 0.36, 95% CI 0.26 to 0.50; 18 studies, 12,249 participants; moderate-certainty evidence). It should be noted that the overall prevalence of acute rheumatic fever was very low, particularly in the later studies.

AUTHORS' CONCLUSIONS

Antibiotics probably reduce the number of people experiencing sore throat, and reduce the likelihood of headache, and some sore throat complications. As the effect on symptoms can be small, clinicians must judge on an individual basis whether it is clinically justifiable to use antibiotics to produce this effect, and whether the underlying cause of the sore throat is likely to be of bacterial origin. Furthermore, the balance between modest symptom reduction and the potential hazards of antimicrobial resistance must be recognised. Few trials have attempted to measure symptom severity. If antibiotics reduce the severity as well as the duration of symptoms, their benefit will have been underestimated in this meta-analysis. Additionally, more trials are needed in low-income countries, in socio-economically deprived sections of high-income countries, as well as in children.

Antibiotics for Fever Among Children: Findings From the Surveillance for Enteric Fever in India Cohorts

Background

Acute febrile illness in children is frequently treated with antibiotics. However, the inappropriate use of antibiotics has led to the emergence of multidrug-resistant pathogens.

Methods

We measured use of antibiotics for fever in 4 pediatric cohorts that were part of the Surveillance for Enteric Fever in India (SEFI) network. In this network, 24 062 children were followed up weekly, capturing information on fever and other morbidity between October 2017 and December 2019.

Results

An antibiotic was given in 27 183 of the 76 027 (35.8%) episodes of fever. The incidence of fever-related antibiotic use was 58.0 (95% confidence interval [CI], 57.2–58.6) per 100 child-years. The median time to initiation of antibiotics was 4 days, and in 65% of those who received an antibiotic it was initiated by the second day. Antibiotics were continued for &lt;3 days in 24% of the episodes. Higher temperature, younger age, male sex, joint family, higher education, internet access, and availability of personal conveyance were associated with antibiotic treatment for fever.

Conclusions

In developing countries where antibiotic use is not regulated, broad-spectrum antibiotics are initiated early, and often inappropriately, in febrile illness. Frequent and inappropriate use of antibiotics may increase risk of antimicrobial resistance.

Quantifying the Gap between Expected and Actual Rates of Antibiotic Prescribing in British Columbia, Canada

Despite decades of stewardship efforts to combat antimicrobial resistance and quantify changes in use, the quality of antibiotic use in British Columbia (BC) remains unknown. As the overuse and misuse of antibiotics drives antibiotic resistance, it is imperative to expand surveillance efforts to examine the quality of antibiotic prescriptions. In late 2019, Canadian expected rates of antibiotic prescribing were developed for common infections. These rates were utilized to quantify the gap between the observed rates of prescribing and Canadian expected rates for antibiotic use for the province of BC. The prescribing data were extracted and matched to physician billing systems using anonymized patient identifiers from 1 January 2000 to 31 December 2018. Outpatient prescribing was further subdivided into community and emergency department settings and stratified by the following age groups: <2 years, 2-18 years, and ≥19 years. The proportions of physician visits that received antibiotic prescription were compared against the Canadian expected rates to quantify the unnecessary use for 18 common indications. Respiratory tract infections (RTI), including acute bronchitis, acute sinusitis, and acute pharyngitis, reported significant levels of overprescribing. Across all ages and health care settings, prescribing for RTI indications occurred at rates 2-8 times higher than the expected rates recommended by a group of expert Canadian physicians. Understanding the magnitude of unnecessary prescribing is a first step in delineating the provincial prescribing quality. The quantification of antibiotic overuse offers concrete targets for provincial stewardship efforts to reduce unnecessary prescribing by an average of 30% across both outpatient and emergency care settings.

Metrics for evaluating antibiotic use and prescribing in outpatient settings

Antimicrobial stewardship interventions in outpatient settings are diverse and a variety of outcomes have been used to evaluate these efforts. This narrative review describes, compares and provides specific examples of antibiotic use and other prescribing measures to help antimicrobial stewards better understand, interpret and implement metrics for this setting. A variety of data have been used including those generated from drug sales, prescribing and dispensing activities, however data generated closest to when an individual patient consumes an antibiotic is usually more accurate for estimating antibiotic use. Availability of data is often dependent on context such as information technology infrastructure and the healthcare system under consideration. While there is no ideal antibiotic use or prescribing metric for evaluating antimicrobial stewardship activities in the outpatient setting, the intervention of interest and available data sources are important factors. Common metrics for estimating antimicrobial use include DDD per 1000 inhabitants per day (DID) and days of therapy per 1000 inhabitants/day (DOTID). Other prescribing metrics such as antibiotic prescribing rate (APR), proportion of prescriptions containing an antibiotic, proportion of prolonged antibiotic courses prescribed, estimated appropriate APR and quality indicators are used to assess specific aspects of antimicrobial prescribing behaviour such as initiation, selection, duration and appropriateness. Understanding the context of prescribing practices helps to ensure feasibility and relevance when implementing metrics and targets for improvement in the outpatient setting.

Estrategias de protección antimicrobiana en el cuidado de heridas: evidencia para el uso de apósitos recubiertos con DACC

BACKGROUND

Antimicrobial resistance (AMR) is one of the most serious health threats globally. The development of new antimicrobials is not keeping pace with the evolution of resistant microorganisms, and novel ways of tackling this problem are required. One of such initiatives has been the development of antimicrobial stewardship programmes (AMS). The use of wound dressings that employ a physical sequestration and retention approach to reduce bacterial burden offers a novel approach to support AMS. Bacterial-binding by dressings and their physical removal can minimise their damage and prevent the release of harmful endotoxins.

OBJECTIVE

To highlight AMS to promote the correct use of antimicrobials and to investigate how dialkylcarbamyl chloride (DACC)-coated dressings can support AMS.

METHOD

MEDLINE, Cochrane Database of Systematic Reviews, and Google Scholar were searched to identify articles relating to AMS, and the use of wound dressings in the prevention and treatment of wound infections. The evidence supporting alternative wound dressings that can reduce bioburden and prevent wound infection in a way that does not kill or damage the microorganisms were reviewed.

RESULTS

The evidence demonstrated that using bacterial-binding wound dressings that act in a physical manner (eg, DACC-coated dressings) to preventing infection in both acute and hard-to-heal wounds does not exacerbate AMR and supports AMS.

CONCLUSION

Some wound dressings work via a mechanism that promotes the binding and physical sequestration and removal of intact microorganisms from the wound bed (eg, a wound dressing that uses DACC technology to prevent/reduce infection). They provide a valuable tool that aligns with the requirements of AMS by effectively reducing wound bioburden without inducing/selecting for resistant bacteria.

Antimicrobial stewardship in rural and remote primary health care: a narrative review

BACKGROUND

Antimicrobial resistance is an emerging problem worldwide and poses a significant threat to human health. Antimicrobial stewardship programmes are being implemented in health systems globally, primarily in hospitals, to address the growing threat of antimicrobial resistance. Despite the significance of primary health care services in providing health care to communities, antimicrobial stewardship programmes are not well established in this sector, especially in rural and remote settings. This narrative review aims to identify in rural and remote primary health care settings the (1) correlation of antimicrobial resistance with antibiotic prescribing and volume of antibiotic use, (2) appropriateness of antimicrobial prescribing, (3) risk factors associated with inappropriate use/prescribing of antibiotics, and (4) effective antimicrobial stewardship strategies.

METHODS

The international literature was searched for English only articles between 2000 and 2020 using specified keywords. Seven electronic databases were searched: Scopus, Cochrane, Embase, CINAHL, PubMed, Ovid Medline and Ovid Emcare. Publication screening and analysis were conducted using Joanna Briggs Institute systematic review tools.

RESULTS

Fifty-one eligible articles were identified. Inappropriate and excessive antimicrobial prescribing and use directly led to increases in antimicrobial resistance. Increasing rurality of practice is associated with disproportionally higher rates of inappropriate prescribing compared to those in metropolitan areas. Physician knowledge, attitude and behaviour play important roles in mediating antimicrobial prescribing, with strong intrinsic and extrinsic influences including patient factors. Antimicrobial stewardship strategies in rural and remote primary health care settings focus on health care provider and patient education, clinician support systems, utility of antimicrobial resistance surveillance, and policy changes. Results of these interventions were generally positive with decreased antimicrobial resistance rates and improved appropriateness of antimicrobial prescribing.

CONCLUSIONS

Inappropriate prescribing and excessive use of antimicrobials are an important contributor to the increasing resistance towards antimicrobial agents particularly in rural and remote primary health care. Antimicrobial stewardship programmes in the form of education, clinical support, surveillance, and policies have been mostly successful in reducing prescribing rates and inappropriate prescriptions. The narrative review highlighted the need for longer interventions to assess changes in antimicrobial resistance rates. The review also identified a lack of differentiation between rural and remote contexts and Indigenous health was inadequately addressed. Future research should have a greater focus on effective interventional components and patient perspectives.

Antibiotic use and deprivation: an analysis of Welsh primary care antibiotic prescribing data by socioeconomic status

OBJECTIVES

To examine the association between socioeconomic status (SES) and antibiotic prescribing, controlling for the presence of common chronic conditions and other potential confounders and variation amongst GP practices and clusters.

METHODS

This was an electronic cohort study using linked GP and Welsh Index of Multiple Deprivation (WIMD) data. The setting was GP practices contributing to the Secure Anonymised Information Linkage (SAIL) Databank 2013-17. The study involved 2.9 million patients nested within 339 GP practices, nested within 67 GP clusters.

RESULTS

Approximately 9 million oral antibiotics were prescribed between 2013 and 2017. Antibiotic prescribing rates were associated with WIMD quintile, with more deprived populations receiving more antibiotics. This association persisted after controlling for patient demographics, smoking, chronic conditions and clustering by GP practice and cluster, with those in the most deprived quintile receiving 18% more antibiotic prescriptions than those in the least deprived quintile (incidence rate ratio = 1.18; 95% CI = 1.181-1.187). We found substantial unexplained variation in antibiotic prescribing rates between GP practices [intra-cluster correlation (ICC) = 47.31%] and GP clusters (ICC = 12.88%) in the null model, which reduced to ICCs of 3.50% and 0.85% for GP practices and GP clusters, respectively, in the final adjusted model.

CONCLUSIONS

Antibiotic prescribing in primary care is increased in areas of greater SES deprivation and this is not explained by differences in the presence of common chronic conditions or smoking status. Substantial unexplained variation in prescribing supports the need for ongoing antimicrobial stewardship initiatives.

Improving antibiotic use through behaviour change: a systematic review of interventions evaluated in low- and middle-income countries

Antibiotic resistance (ABR) has been identified as a critical threat to global health at the highest policy fora. A leading cause of ABR is the inappropriate use of antibiotics by both patients and healthcare providers. Although countries around the world have committed to developing and implementing national action plans to tackle ABR, there is a considerable gap in evidence about effective behaviour change interventions addressing inappropriate use of antibiotics in low- and middle-income countries (LMICs), where ABR is growing at an alarming rate. We conducted a systematic review to synthesize evidence about the effectiveness and cost-effectiveness of behaviour change interventions to reduce inappropriate use of antibiotics in LMICs. Three databases were searched using a set of predefined search terms and exclusion criteria. The search identified 43 relevant articles. A narrative synthesis of results was conducted using the Behaviour Change Wheel framework to categorize intervention components. The majority of the reviewed studies were set in lower-middle-income or low-income countries located in Sub-Saharan Africa or East Asia and the Pacific. Twenty-four articles evaluated multi-faceted interventions over a period of 12 months or less. Despite the widespread use of antibiotics in the community, interventions were primarily implemented in public health facilities, targeting health professionals such as doctors, nurses, and other allied medical staff. Although education for providers was the most widely used strategy for influencing antibiotic use, it was shown to be most effective when used in conjunction with training or other enabling and supportive measures to nudge behaviour. Six articles included an evaluation of costs of interventions and found a reduction in costs in inpatient and outpatient settings, and one article found a training and guidelines implementation-based intervention to be highly cost-effective. However, the small number of articles conducting an economic evaluation highlights the need for such analyses to be conducted more frequently to support priority setting in resource-constrained environments.

Appropriateness of antibiotic prescriptions in ambulatory care in China: a nationwide descriptive database study

BACKGROUND

Inappropriate antibiotic use greatly accelerates antimicrobial resistance. The appropriateness of antibiotic prescriptions is well evaluated, using big observational data, in some high-income countries, whereas the evidence of this appropriateness is scarce in China. We aimed to assess the appropriateness of antibiotic prescriptions in ambulatory care settings in China to inform future antimicrobial stewardship.

METHODS

We used data from the Beijing Data Center for Rational Use of Drugs, which was a national database designed for monitoring rationality of drug use. 139 hospitals that uploaded diagnosis and prescription information were included from 28 provincial-level regions of mainland China. Outpatient prescriptions were classified as appropriate, potentially appropriate, inappropriate, or not linked to any diagnosis for antibiotic use by following a published classification scheme. Antibiotic prescription rates for various diagnosis categories and proportions of inappropriate antibiotic prescriptions for different subgroups were estimated. Antibiotic prescribing patterns and proportions of individual antibiotics prescribed for different diagnosis categories were analysed and reported.

FINDINGS

Between Oct 1, 2014, and April 30, 2018, 18 848 864 (10·9%) of 172 704 117 outpatient visits ended with antibiotic prescriptions. For conditions for which antibiotic use was appropriate, potentially appropriate, and inappropriate, 42·2%, 30·6%, and 7·6% of visits were associated with antibiotic prescriptions, respectively. Of all 18 848 864 antibiotic prescriptions, 9 689 937 (51·4%) were inappropriate, 5 354 224 (28·4%) were potentially appropriate, 2 893 102 (15·3%) were appropriate, and 911 601 (4·8%) could not be linked to any diagnosis. A total of 23 266 494 individual antibiotics were prescribed, of which 18 620 086 (80·0%) were broad-spectrum and the top four most prescribed antibiotics were third-generation cephalosporins (5 056 058 [21·7%]), second-generation cephalosporins (3 823 410 [16·4%]), macrolides (3 554 348 [15·3%]), and fluoroquinolones (3 285 765 [14·1%]).

INTERPRETATION

Inappropriate antibiotic prescribing was highly prevalent nationwide in China. Over half of the antibiotic prescriptions were inappropriate in secondary-level and tertiary-level hospitals, suggesting an urgent need for outpatient antibiotic stewardship aimed at optimising antibiotic prescribing to achieve the goals set in China's 2016 national action plan to contain antimicrobial resistance.

FUNDING

The National Natural Science Foundation of China.

The Association Between High and Unnecessary Antibiotic Prescribing: A Cohort Study Using Family Physician Electronic Medical Records

BACKGROUND

Approximately 25% of outpatient antibiotic prescriptions are unnecessary among family physicians in Canada. Minimizing unnecessary antibiotics is key for community antibiotic stewardship. However, unnecessary antibiotic prescribing is much harder to measure than total antibiotic prescribing. We investigated the association between total and unnecessary antibiotic use by family physicians and evaluated inter-physician variability in unnecessary antibiotic prescribing.

METHODS

This was a cohort study based on electronic medical records of family physicians in Ontario, Canada, between April 2011 and March 2016. We used predefined expected antibiotic prescribing rates for 23 common primary care conditions to calculate unnecessary antibiotic prescribing rates. We used multilevel Poisson regression models to evaluate the association between total antibiotic volume (number of antibiotic prescriptions per patient visit), adjusted for multiple practice- and physician-level covariates, and unnecessary antibiotic prescribing.

RESULTS

There were 499 570 physician-patient encounters resulting in 152 853 antibiotic prescriptions from 341 physicians. Substantial inter-physician variability was observed. In the fully adjusted model, we observed a significant association between total antibiotic volume and unnecessary prescribing rate (adjusted rate ratio 2.11 per 10% increase in total use; 95% CI 2.05-2.17), and none of the practice- and physician-level variables were associated with unnecessary prescribing rate.

CONCLUSIONS

We demonstrated substantial inter-physician variability in unnecessary antibiotic prescribing in this cohort of family physicians. Total antibiotic use was strongly correlated with unnecessary antibiotic prescribing. Total antibiotic volume is a reasonable surrogate for unnecessary antibiotic use. These results can inform community antimicrobial stewardship efforts.

Antimicrobial stewardship strategies in wound care: evidence to support the use of dialkylcarbamoyl chloride (DACC)- coated wound dressings

BACKGROUND

Traditionally, infections are treated with antimicrobials (for example, antibiotics, antiseptics, etc), but antimicrobial resistance (AMR) has become one of the most serious health threats of the 21st century (before the emergence of COVID-19). Wounds can be a source of infection by allowing unconstrained entry of microorganisms into the body, including antimicrobial-resistant bacteria. The development of new antimicrobials (particularly antibiotics) is not keeping pace with the evolution of resistant microorganisms and novel ways of addressing this problem are urgently required. One such initiative has been the development of antimicrobial stewardship (AMS) programmes, which educate healthcare workers, and control the prescribing and targeting of antimicrobials to reduce the likelihood of AMR. Of great importance has been the European Wound Management Association (EWMA) in supporting AMS by providing practical recommendations for optimising antimicrobial therapy for the treatment of wound infection. The use of wound dressings that use a physical sequestration and retention approach rather than antimicrobial agents to reduce bacterial burden offers a novel approach that supports AMS. Bacterial-binding by dressings and their physical removal, rather than active killing, minimises their damage and hence prevents the release of damaging endotoxins.

AIM

Our objective is to highlight AMS for the promotion of the judicious use of antimicrobials and to investigate how dialkylcarbamoyl chloride (DACC)-coated dressings can support AMS goals.

METHOD

MEDLINE, Cochrane Database of Systematic Reviews, and Google Scholar were searched to identify published articles describing data relating to AMS, and the use of a variety of wound dressings in the prevention and/or treatment of wound infections. The evidence supporting alternative wound dressings that can reduce bioburden and prevent and/or treat wound infection in a manner that does not kill or damage the microorganisms (for example, by actively binding and removing intact microorganisms from wounds) were then narratively reviewed.

RESULTS

The evidence reviewed here demonstrates that using bacterial-binding wound dressings that act in a physical manner (for example, DACC-coated dressings) as an alternative approach to preventing and/or treating infection in both acute and hard-to-heal wounds does not exacerbate AMR and supports AMS.

CONCLUSION

Some wound dressings work via a mechanism that promotes the binding and physical uptake, sequestration and removal of intact microorganisms from the wound bed (for example, a wound dressing that uses DACC technology to successfully prevent/reduce infection). They provide a valuable tool that aligns with the requirements of AMS (for example, reducing the use of antimicrobials in wound treatment regimens) by effectively reducing wound bioburden without inducing/selecting for resistant bacteria.

Outpatient antibiotic use attributable to viral acute lower respiratory tract infections during the cold season in France, 2010-2017

Antibiotic stewardship requires clear insight into antibiotic overuse and the syndromes that lead to prescription. The aim of this study was to estimate the proportion of antibiotic prescriptions attributable to acute lower respiratory tract infections (LRTIs) during the cold season. Using individual data from the French National Health Insurance (NHI) database, weekly time series were constructed of outpatient antibiotic (beta-lactams and macrolides) prescriptions between January 2010 and December 2017. Time series were also constructed of tenth edition of the International Classification of Diseases (ICD-10) discharge diagnoses from a national network of emergency departments (EDs), stratified by specific syndromes (pneumonia, bronchitis, bronchiolitis and influenza-like illness). The number of outpatient antibiotic prescriptions attributable to these syndromes during the cold season in France was modeled and estimated for the entire population, young children (≤5 years) and the elderly (≥75 years). LRTIs accounted for 40% (95% confidence interval [95% CI]: 29, 52) of outpatient antibiotic use during the cold season for the entire population, including 23% (95% CI: 13, 33) and 17% (95% CI: 13, 22) for bacterial and viral infections, respectively. In children and the elderly, viral LRTIs were the reason for 38% (95% CI: 31, 46) and 20% (95% CI: 16, 25) of outpatient antibiotic use, respectively (with bronchiolitis accountable for half of use in young children). In the entire population and in children, respectively, outpatient antibiotic overuse attributable to viral LRTIs was estimated to be 289 (95% CI: 221, 374) and 1588 (95% CI: 1295, 1922) prescriptions per 100 000 inhabitants per week. These results highlight the major role of viral infections in driving antibiotic prescriptions, particularly in young children.

Protocol for an 'efficient design' cluster randomised controlled trial to evaluate a complex intervention to improve antibiotic prescribing for CHIldren presenting to primary care with acute COugh and respiratory tract infection: the CHICO study

INTRODUCTION

Respiratory tract infections (RTIs) in children are common and present major resource implications for primary care. Unnecessary use of antibiotics is associated with the development and proliferation of antimicrobial resistance. In 2016, the National Institute for Health Research (NIHR)-funded 'TARGET' programme developed a prognostic algorithm to identify children with acute cough and RTI at very low risk of 30-day hospitalisation and unlikely to need antibiotics. The intervention includes: (1) explicit elicitation of parental concerns, (2) the results of the prognostic algorithm accompanied by prescribing guidance and (3) provision of a printout for carers including safety netting advice. The CHIldren's COugh feasibility study suggested differential recruitment of healthier patients in control practices. This phase III 'efficiently designed' trial uses routinely collected data at the practice level, thus avoiding individual patient consent. The aim is to assess whether embedding a multifaceted intervention into general practitioner (GP) practice Information Technology (IT) systems will result in reductions of antibiotic prescribing without impacting on hospital attendance for RTI.

METHODS AND ANALYSIS

The coprimary outcomes are (1) practice rate of dispensed amoxicillin and macrolide antibiotics, (2) hospital admission rate for RTI using routinely collected data by Clinical Commissioning Groups (CCGs). Data will be collected for children aged 0-9 years registered at 310 practices (155 intervention, 155 usual care) over a 12-month period. Recruitment and randomisation of practices (using the Egton Medical Information Systems web data management system) is conducted via each CCG stratified for children registered and baseline dispensing rates of each practice. Secondary outcomes will explore intervention effect modifiers. Qualitative interviews will explore intervention usage. The economic evaluation will be limited to a between-arm comparison in a cost-consequence analysis.

ETHICS AND DISSEMINATION

Research ethics approval was given by London-Camden and Kings Cross Research Ethics Committee (ref:18/LO/0345). This manuscript refers to protocol V.4.0. Results will be disseminated through peer-reviewed journals and international conferences.

TRIAL REGISTRATION NUMBER

ISRCTN11405239.

COVID-19: Clouds Over the Antimicrobial Resistance Landscape

In recent years, the increase in antimicrobial resistance (AMR) has been recognized as a real threat to human and animal health. It is a problem that has been given the highest priority, uniting nations in the fight against its causes and effects. Among the actions that have been implemented are: clinical and microbiological surveillance, promotion of rational and controlled use of antibiotics, AMR stewardship programs in hospitals, development of tools for rapid diagnosis of infectious diseases to establish prompt and adequate treatment, and radically improving vaccination strategies. The current COVID-19 pandemic has placed disproportionate demands on the healthcare infrastructure and economy worldwide, which will negatively impact on the availability of materials as well as the technical capacity for diagnosis, patient care, and treatment of both COVID-19 and non-COVID-19 patients. Disruptions to production and distribution chains will hamper the availability and usage of antibiotics, also interrupting several of the activities that have been implemented thus far to combat AMR, including detailed laboratory monitoring and reinforced vaccination programs. Here, we discuss the main aspects that should be considered with regard to AMR, that may be affected by the pandemic and propose some actions to counter them.

Antimicrobial never events: Objective application of a framework to assess vancomycin appropriateness

To address appropriateness of antibiotic use, we implemented an electronic framework to evaluate antibiotic "never events" (NEs) at 2 medical centers. Patient-level vancomycin administration records were classified as NEs or non-NEs. The objective framework allowed capture of true-positive vancomycin NEs in one-third of patients identified by the electronic strategy.

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

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.

High prescribing rates of third-generation cephalosporins in children hospitalized with acute lower respiratory infections at a university hospital

OBJECTIVE

Antibiotics are frequently prescribed for the treatment of acute lower respiratory infections (ALRI) in children ≤5 years of age, even though viral aetiologies are the most common. The aim of this study was to describe antibiotic prescribing rates and patterns in children ≤5 years of age hospitalized with ALRI.

METHODS

A retrospective study was conducted involving patients aged 1 month to 5 years hospitalized with ALRI at a university hospital. Patient demographics, ALRI diagnosis, microbiological data, antibiotics prescribed, and treatment outcomes were recorded and analysed.

RESULTS

A total of 1283 patients were enrolled. Their median age was 1.6 years (interquartile range 0.8-2.8 years). Thirty-six percent had a co-morbidity. The diagnosis at discharge was viral ALRI in 81% and bacterial pneumonia in 19%. The mortality rate was 0.4%. The overall antibiotic prescribing rate was 46% (95% confidence interval 43-49%). Antibiotic prescribing rates were higher among children with co-morbidities (65% vs 35%, p < 0.001) and older children (57% for >2-5 years vs 39% for ≤2 years, p < 0.001). Parenteral third-generation cephalosporins were prescribed in up to 68% of all prescriptions.

CONCLUSIONS

Nearly-half of hospitalized children with ALRI were prescribed antibiotics. The majority of prescribed antibiotics were third-generation cephalosporins. An antimicrobial stewardship programme and antibiotic guidelines should be implemented to promote the judicious use of antibiotics.

Proxy indicators to estimate the appropriateness of medications prescribed by paediatricians in infectious diseases: a cross-sectional observational study based on reimbursement data

Background

We previously developed proxy indicators (PIs) that can be used to estimate the appropriateness of medications used for infectious diseases (in particular antibiotics) in primary care, based on routine reimbursement data that do not include clinical indications.

Objectives

To: (i) select the PIs that are relevant for children and estimate current appropriateness of medications used for infectious diseases by French paediatricians and its variability while using these PIs; (ii) assess the clinimetric properties of these PIs using a large regional reimbursement database; and (iii) compare performance scores for each PI between paediatricians and GPs in the paediatric population.

Methods

For all individuals living in north-eastern France, a cross-sectional observational study was performed analysing National Health Insurance data (available at prescriber and patient levels) regarding antibiotics prescribed by their paediatricians in 2017. We measured performance scores of the PIs, and we tested their clinimetric properties, i.e. measurability, applicability and room for improvement.

Results

We included 116 paediatricians who prescribed a total of 44 146 antibiotic treatments in 2017. For all four selected PIs (seasonal variation of total antibiotic use, amoxicillin/second-line antibiotics ratio, co-prescription of anti-inflammatory drugs and antibiotics), we found large variations between paediatricians. Regarding clinimetric properties, all PIs were measurable and applicable, and showed high improvement potential. Performance scores did not differ between these 116 paediatricians and 3087 GPs.

Conclusions

This set of four proxy indicators might be used to estimate appropriateness of prescribing in children in an automated way within antibiotic stewardship programmes.

Outpatient antibiotic use associated with acute upper respiratory infections in China: a nationwide cross-sectional study

BACKGROUND

The assessment of antibiotic use for acute upper respiratory infections (AURIs) is important to promote the appropriateness of antibiotic prescribing. Evaluation of antibiotic prescriptions for AURIs at a national level is very limited in China.

OBJECTIVE

To investigate outpatient antibiotic prescriptions for AURIs in Chinese hospitals.

METHODS

This study used data from over 10 million outpatient and emergency department visits for AURIs, which contained information on drug prescription and diagnosis, from 94 cities and 28 provinces of mainland China. Antibiotic prescription rates for various subgroups and potential predictors of antibiotic use were estimated. Patterns of antibiotic prescriptions and proportions of individual antibiotics prescribed for different types of AURIs were analysed and reported.

RESULTS

In total, 10 770 219 outpatient visits for AURIs were included in this study. Of these, 40.8% (95% confidence interval 40.7-40.8%) resulted in antibiotic prescriptions. Patient characteristics, including age, gender, payment type, AURI type, department and season of visit, were significantly associated with antibiotic prescriptions for AURIs. In total, 4 984 744 antibiotic agents were prescribed, of which 87.9% were broad-spectrum antibiotics and only 36.8% were prescribed in line with the guideline recommendations. Azithromycin (13.2%), cefdinir (11.7%), cefixime (8.3%) and cefaclor (8.2%) were the most commonly prescribed antibiotics for AURIs in China.

CONCLUSIONS

Antibiotic prescribing for patients with AURIs in outpatient settings was prevalent nationwide in China. Antibiotic stewardship efforts targeting specific populations in outpatient settings are needed to reduce antibiotic use and promote appropriate antibiotic selection for AURIs in China.

Delayed Antibiotic Prescription by General Practitioners in the UK: A Stated-Choice Study

Delayed antibiotic prescription in primary care has been shown to reduce antibiotic consumption, without increasing risk of complications, yet is not widely used in the UK. We sought to quantify the relative importance of factors affecting the decision to give a delayed prescription, using a stated-choice survey among UK general practitioners. Respondents were asked whether they would provide a delayed or immediate prescription in fifteen hypothetical consultations, described by eight attributes. They were also asked if they would prefer not to prescribe antibiotics. The most important determinants of choice between immediate and delayed prescription were symptoms, duration of illness, and the presence of multiple comorbidities. Respondents were more likely to choose a delayed prescription if the patient preferred not to have antibiotics, but consultation length had little effect. When given the option, respondents chose not to prescribe antibiotics in 51% of cases, with delayed prescription chosen in 21%. Clinical features remained important. Patient preference did not affect the decision to give no antibiotics. We suggest that broader dissemination of the clinical evidence supporting use of delayed prescription for specific presentations may help increase appropriate use. Establishing patient preferences regarding antibiotics may help to overcome concerns about patient acceptance. Increasing consultation length appears unlikely to affect the use of delayed prescription.

National Trends in Oral Antibiotic Prescribing in United States Physician Offices from 2009 to 2016

BACKGROUND

Prior studies have found that outpatient antibiotics are commonly prescribed for non-bacterial conditions. It is unclear if national prescribing has changed in recent years given recent public health and antimicrobial stewardship initiatives. This study aimed to describe antibiotic prescribing in United States (U.S.) physician offices.

MATERIALS/METHODS

This was a cross-sectional study of all sampled patient visits in the Centers for Disease Control and Prevention's National Ambulatory Medical Care Survey from 2009 to 2016. Antibiotic use was defined as at least one oral antibiotic prescription during the visit as identified by Multum code(s). Patient visits were categorized by U.S. geographic region and season. ICD-9-CM and ICD-10 codes were used to assess diagnoses and categorize antibiotic use as appropriate, possibly appropriate, or inappropriate.

RESULTS

Seven billion visits were included for analysis, with 793,415,182 (11.3%) including an antibiotic. Prescribing rates were relatively stable over the study period (102.9-124.9 prescriptions per 1000 visits); however, 2016 had one of the lowest prescribing rates (107.7 per 1000 visits). The most commonly prescribed antibiotic class was macrolides (25 per 1000 visits). The South region and winter season had the highest antibiotic prescribing (118.2 and 129.7 per 1000 visits, respectively). Of patients who received an antibiotic, 55.9%, 35.7%, and 8.4% were classified as inappropriate, possibly appropriate, and appropriate, respectively. The most common conditions in which antibiotics were prescribed inappropriately included those with no indication in any of the predefined diagnosis codes (40.1%), other skin conditions (17.3%), and viral upper respiratory conditions (13.3%).

CONCLUSIONS

There was no significant reduction in outpatient antibiotic prescribing rates among U.S. outpatients from 2009 to 2016 and prescribing varied by region and season. These data suggest that more than half of antibiotics were prescribed inappropriately, with the majority of antibiotics prescribed with no indication. However, these findings need to be confirmed with robust prospective studies.

Understanding consumer behavior patterns in antibiotic usage for upper respiratory tract infections: A study protocol based on the COM-B framework

BACKGROUND

Irrational use of antibiotics is prevalent worldwide. But our understanding on consumer behaviors in the use of antibiotics is very limited. This study aims to identify consumer behavior patterns in the use of antibiotics for upper respiratory tract infections (URTIs).

METHODS

The study will employ a mixed methods approach based on the "Capacity & Opportunity & Motivation - Behavior" (COM-B) framework. The COM-B attributes of consumers in relation to the use of antibiotics will be extracted from a systematic literature review. Semi-structured in-depth interviews will be conducted on 20-25 community residents with URTI symptoms over the past three months to illustrate the meaning and implications of the thematic categories of COM-B attributes for the purpose of measurement development. The measurement instruments will be modified and validated through Delphi consultations with 15 experts and a survey of 300 adult residents in Wuhan. A cross-sectional survey using the finalised measurement instruments will be conducted on 2700 adult residents randomly selected from 18 residential communities across 9 municipalities in 3 provinces in China. Multi-level latent class analyses will be performed to categeorise the respondents based on the indicators measuring the behavioral features (need recognition, information searching, alternative assessment, purchase, use, and post-use evaluation) of consumers in purchasing, consuming and disposing antibiotics for URTIs. Multi-nominal regression analyses will be performed to determine the predictors of different behavior patterns.

DISCUSSION

This study aims to classify consumers into distinguished categories of behavior patterns toward the use of antibiotics for URTIs. Such a classification system categories the consumers with similar behavior features into the same group so that better targeted interventions can be developed. The COM-B model adopted in this study can also help us better understand the underlying mechanisms of different behavior patterns of consumers.

An examination of trends in antibiotic prescribing in primary care and the association with area-level deprivation in England

Background

Internationally, there are growing concerns about antimicrobial resistance. This has resulted in increased scrutiny of antibiotic prescribing trends – particularly in primary care where the majority of prescribing occurs. In England, antibiotic prescribing targets are set nationally but little is known about the local context of antibiotic prescribing. This study aimed to examine trends in antibiotic prescribing (including broad-spectrum), and the association with area-level deprivation and region in England.

Methods

Antibiotic prescribing data by GP surgery in England were obtained from NHS Business Service Authority for the years 2014–2018. These data were matched with the Index of Multiple Deprivation (IMD) 2015 at the Lower Layer Super Output Area level Lower Layer Super Output Area (LSOA) level. Linear regression methods were employed to explore the relationship between antibiotic use and area-level deprivation as well as region, after controlling for a range of other confounding variables, including health need, rurality, and ethnicity.

Results

Over time, the amount of antibiotic prescribing significantly reduced from 1.11 items per STAR-PU to 0.96 items per STAR-PU – a reduction of 13.6%. The adjusted models found that, at LSOA level, the most deprived areas of England had the highest levels of antibiotic prescribing (0.03 items per STAR-PU higher). However, broad spectrum antibiotic prescribing exceeding 10% of all antibiotic prescribing within a GP practice was higher in more affluent areas. There were also significant regional differences – with the North East and the East of England having the highest levels of antibiotic prescribing (by 0.16 items per STAR-PU).

Conclusion

Although antibiotic prescribing has reduced over time, there remains significant variation in by area-level deprivation and region in England – with higher antibiotic prescribing in more deprived areas. Future prescribing targets should account for local factors to ensure the most deprived communities are not inappropriately penalised.

Long-term impact of an intervention on rapid antigen detection tests in acute pharyngitis

Objective

This study was aimed at evaluating the appropriateness of use and interpretation of rapid antigen detection testing (RADT) and antibiotic prescribing for acute pharyngitis six years after a multifaceted intervention.

Design

Before-and-after audit-based study.

Location

Primary care centres in eight autonomous Communities.

Participants

General practitioners (GP) who had participated in the HAPPY AUDIT intervention study in 2008 and 2009 were invited to participate in a third audit-based study six years later (2015).

Method

RADTs were provided to the participating practices and the GPs were requested to consecutively register all adults with acute pharyngitis. A registration form specifically designed for this study was used.

Results

A total of 121 GPs out of the 210 who participated in the first two audits agreed to participate in the third audit (57.6%). They registered 3394 episodes of pharyngitis in the three registrations. RADTs were used in 51.7% of all the cases immediately after the intervention, and in 49.4% six years later. Antibiotics were prescribed in 21.3% and 36.1%, respectively (P < .001), mainly when tonsillar exudates were present, and in 5.3% and 19.2% of those with negative RADT results (P< .001). On adjustment for covariables, compared to the antibiotic prescription observed just after the intervention, significantly more antibiotics were prescribed six years later (odds ratio: 2.24, 95% confidence interval: 1.73–2.89).

Conclusions

This study shows that that the long-term impact of a multifaceted intervention, focusing on the use and interpretation of RADT in patients with acute pharyngitis, is reducing.

The Impact of Physicians' Working Hours on Inappropriate Use of Outpatient Medicine in a Tertiary Hospital in China

BACKGROUND

Inappropriate prescribing is an important health system problem in China. Several studies have identified critical factors influencing prescription quality, but the impact of physicians' working hours remains unknown. In China, tertiary hospitals face ever-increasing outpatient volumes. Physicians are asked to work long hours and the impact of shift duration on prescription quality is unknown.

OBJECTIVE

We aimed to investigate the association between consecutive working hours and the quality of physicians' prescriptions in a Chinese tertiary hospital.

METHODS

We obtained all outpatient electronic health records from the hospital information system (HIS) of a tertiary hospital in Beijing, China from 1 July to 30 November 2015. Prescriptions made during two periods were analyzed: a morning shift from 7:30 to 12:30, and an afternoon shift from 13:30 to 18:30. The time when a physician issued the first prescription was considered the beginning of the work shift and prescriptions within the next 4 consecutive hours were included. Potentially inappropriate prescriptions were based on the Rational Drug Use (RDU) system that was developed and validated for this study. We used multivariable logistic regression to examine the impact of shift duration and other clinical and physician factors on potentially inappropriate prescribing.

RESULTS

Of the total 560,529 prescriptions, 15.3% were classified as inappropriate by the RDU system. Physicians' inappropriate prescribing increased in the last hour in each work shift (odds ratio (OR) for the fourth hour compared to the first = 1.12 (95% CI, 1.09-1.15)). We also found that physicians who worked all day had a higher rate of inappropriate prescribing than those who only worked half a day (OR = 1.05 (95% CI, 1.04-1.07)).

CONCLUSIONS

Longer working hours are a risk factor for inappropriate prescribing. Relevant interventions are urgently needed to establish working hour limits in China to reduce the likelihood of inappropriate prescribing by physicians.

Defining appropriate antibiotic prescribing in primary care: A modified Delphi panel approach

BACKGROUND

Antimicrobial overuse contributes to antimicrobial resistance. In the ambulatory setting, where more than 90% of antibiotics are dispensed, there are no Canadian benchmarks for appropriate use. This study aims to define the expected appropriate outpatient antibiotic prescribing rates for three age groups (<2, 2-18, >18 years) using a modified Delphi method.

METHODS

We developed an online questionnaire to solicit from a multidisciplinary panel (community-academic family physicians, adult-paediatric infectious disease physicians, and antimicrobial stewardship pharmacists) what percentage of 23 common clinical conditions would appropriately be treated with systemic antibiotics followed with in-person meetings to achieve 100% consensus.

RESULTS

The panelists reached consensus for one condition online and 22 conditions face-to-face, which took an average of 2.6 rounds of discussion per condition (range, min-max 1-5). The consensus for appropriate systemic antibiotic prescribing rates were, for pneumonia, pyelonephritis, non-purulent skin and soft tissue infections (SSTI), other bacterial infections, and reproductive tract infections, 100%; urinary tract infections, 95%-100%; prostatitis, 95%; epididymo-orchitis, 85%-88%; chronic obstructive pulmonary disease, 50%; purulent SSTI, 35%-50%; otitis media, 30%-40%; pharyngitis, 18%-40%; acute sinusitis, 18%-20%; chronic sinusitis, 14%; bronchitis, 5%-8%; gastroenteritis, 4%-5%; dental infections, 4%; eye infections, 1%; otitis externa, 0%-1%; and asthma, common cold, influenza, and other non-bacterial infections (0%). (Note that some differed by age group.).

CONCLUSIONS

This study resulted in expert consensus for defined levels of appropriate antibiotic prescribing across a broad set of outpatient conditions. These results can be applied to community antimicrobial stewardship initiatives to investigate the level of inappropriate use and set targets to optimize antibiotic use.

Unnecessary antibiotic prescribing in a Canadian primary care setting: a descriptive analysis using routinely collected electronic medical record data

BACKGROUND

Unnecessary antibiotic use in the community in Canada is not well defined. Our objective was to quantify unnecessary antibiotic prescribing in a Canadian primary care setting.

METHODS

We performed a descriptive analysis in Ontario from April 2011 to March 2016 using the Electronic Medical Records Primary Care database linked to other health administrative data sets at ICES. We determined antibiotic prescribing rates (per 100 patient-physician encounters) for 23 common conditions and estimated rates of unnecessary prescribing using predefined expected prescribing rates, both stratified by condition and patient age group.

RESULTS

The study included 341 physicians, 204 313 patients and 499 570 encounters. The rate of unnecessary antibiotic prescribing for included conditions was 15.4% overall and was 17.6% for those less than 2 years of age, 18.6% for those aged 2-18, 14.5% for those aged 19-64 and 13.0% for those aged 65 or more. The highest unnecessary prescribing rates were observed for acute bronchitis (52.6%), acute sinusitis (48.4%) and acute otitis media (39.3%). The common cold, acute bronchitis, acute sinusitis and miscellaneous nonbacterial infections were responsible for 80% of the unnecessary antibiotic prescriptions. Of all antibiotics prescribed, 12.0% were for conditions for which they are never indicated, and 12.3% for conditions for which they are rarely indicated. In children, 25% of antibiotics were for conditions for which they are never indicated (e.g., common cold).

INTERPRETATION

Antibiotics were prescribed unnecessarily for 15.4% of included encounters in a Canadian primary care setting. Almost one-quarter of antibiotics were prescribed for conditions for which they are rarely or never indicated. These findings should guide safe reductions in the use of antibiotics for the common cold, bronchitis and sinusitis.

Validation of an algorithm to evaluate the appropriateness of outpatient antibiotic prescribing using big data of Chinese diagnosis text

OBJECTIVE

We aimed to evaluate the validity of an algorithm to classify diagnoses according to the appropriateness of outpatient antibiotic use in the context of Chinese free text.

SETTING AND PARTICIPANTS

A random sample of 10 000 outpatient visits was selected between January and April 2018 from a national database for monitoring rational use of drugs, which included data from 194 secondary and tertiary hospitals in China.

RESEARCH DESIGN

Diagnoses for outpatient visits were classified as tier 1 if associated with at least one condition that 'always' justified antibiotic use; as tier 2 if associated with at least one condition that only 'sometimes' justified antibiotic use but no conditions that 'always' justified antibiotic use; or as tier 3 if associated with only conditions that never justified antibiotic use, using a tier-fashion method and regular expression (RE)-based algorithm.

MEASURES

Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of the classification algorithm, using classification made by chart review as the standard reference, were calculated.

RESULTS

The sensitivities of the algorithm for classifying tier 1, tier 2 and tier 3 diagnoses were 98.2% (95% CI 96.4% to 99.3%), 98.4% (95% CI 97.6% to 99.1%) and 100.0% (95% CI 100.0% to 100.0%), respectively. The specificities were 100.0% (95% CI 100.0% to 100.0%), 100.0% (95% CI 99.9% to 100.0%) and 98.6% (95% CI 97.9% to 99.1%), respectively. The PPVs for classifying tier 1, tier 2 and tier 3 diagnoses were 100.0% (95% CI 99.1% to 100.0%), 99.7% (95% CI 99.2% to 99.9%) and 99.7% (95% CI 99.6% to 99.8%), respectively. The NPVs were 99.9% (95% CI 99.8% to 100.0%), 99.8% (95% CI 99.7% to 99.9%) and 100.0% (95% CI 99.8% to 100.0%), respectively.

CONCLUSIONS

The RE-based classification algorithm in the context of Chinese free text had sufficiently high validity for further evaluating the appropriateness of outpatient antibiotic prescribing.

Storytelling as a research tool and intervention around public health perceptions and behaviour: a protocol for a systematic narrative review

INTRODUCTION

There is a growing trend to use storytelling as a research tool to extract information and/or as an intervention to effect change in the public knowledge, attitudes and behaviour (KAB) in relation to public health issues, primarily those with a strong element of disease prevention. However, evidence of its use in either or both capacities is limited. This protocol proposes a systematic narrative review of peer-reviewed, published literature on the use of storytelling as a research tool within the public health arena.

METHODS AND ANALYSIS

Medline, EMBASE, PsycINFO, ERIC (Educational Resources Information Center), Web of Science, Art and Humanities database (ProQuest), Scopus and Google Scholar will be searched for studies that look at the use of storytelling in the research of pressing current public health issues, for example, vaccinations, antimicrobial resistance, climate change and cancer screening. The review will synthesise evidence of how storytelling is used as a research tool to (a) gain insights into KAB and (b) to effect change in KAB when used as an intervention. Included studies will be selected according to carefully defined criteria relevant to public health issues of interest, and data from qualitative, quantitative and mixed-methods studies will be extracted with a customised data extraction form. A narrative synthesis will be performed according to Economic and Social Research Council guidance from Popay, J, 2006.The study protocol follows the recommendations by the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P).

ETHICS AND DISSEMINATION

Formal ethical approval is not required for this study, as no primary data will be collected. Dissemination will involve publishing results of this study in relevant peer-reviewed journal(s). Where possible, the study results will also be presented as posters or talks at relevant medical conferences and meetings.

PROSPERO REGISTRATION NUMBER

CRD42019124704.

Understanding the Context of High- and Low-Testosterone Prescribing Facilities in the Veterans Health Administration (VHA): a Qualitative Study

BACKGROUND

Inappropriate testosterone use and variations in testosterone prescribing patterns exist in the Veterans Health Administration (VHA) despite the presence of clinical guidelines.

OBJECTIVE

We examined system and clinician factors that contribute to patterns of potentially inappropriate testosterone prescribing in VHA.

DESIGN

Qualitative study using a positive deviance approach to understand practice variation in high- and low-testosterone prescribing sites.

PARTICIPANTS

Twenty-two interview participants included primary care and specialty clinicians, key opinion leaders, and pharmacists at 3 high- and 3 low-testosterone prescribing sites.

APPROACH

Semi-structured phone interviews were conducted, transcribed, and coded using a priori theoretical constructs and emergent themes. Case studies were developed for each site and a cross-case matrix was created to evaluate variation across high- and low-prescribing sites.

KEY RESULTS

We identified four system-level domains related to variation in testosterone prescribing: organizational structures and processes specific to testosterone prescribing, availability of local guidance on testosterone prescribing, well-defined dissemination process for local testosterone polices, and engagement in best practices related to testosterone prescribing. Two clinician-level domains were also identified, specifically, structured initial testosterone prescribing process and specified follow-up testosterone prescribing process. High- and low-testosterone prescribing sites systematically varied in the four system-level domains, while the clinician-level domains looked similar across all sites. The third high-prescribing site was unusual in that it exhibited the four domains similar to the 3 low-prescribing sites at the time of our visit. This site had greatly reduced its prescribing of testosterone in the interim.

CONCLUSIONS

Findings suggest that local organizational factors play an important role in influencing prescribing. Sites have the potential to transform their utilization patterns by providing access to specialty care expertise, an electronic health record-based system to facilitate guideline-concordant prescribing, well-defined dissemination processes for information, guidance from multiple sources, and clarity regarding best practices for prescribing.