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Omar M, Kassem E, Anis E, Abu-Jabal R, Mwassi B, Shulman L, Cohen D, Muhsen K. Factors associated with antibiotic use in children hospitalized for acute viral gastroenteritis and the relation to rotavirus vaccination. Hum Vaccin Immunother 2024; 20:2396707. [PMID: 39248509 PMCID: PMC11385160 DOI: 10.1080/21645515.2024.2396707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Revised: 07/29/2024] [Accepted: 08/22/2024] [Indexed: 09/10/2024] Open
Abstract
Evidence on unnecessary antibiotic use in children with acute viral gastroenteritis (AGE) is scarce. We characterized the extent and correlates of antibiotic use among children hospitalized with viral AGE. A single-center study enrolled children aged 0-59 months hospitalized for AGE between 2008 and 2015 in Israel. Information was collected on laboratory tests, diagnoses, antibiotic treatment, and rotavirus vaccination. Stool samples were tested for rotavirus antigen, GII-norovirus, and stool cultures were performed for bacterial enteropathogens. Data from 2240 children were analyzed. Rotavirus vaccine was given to 79% of eligible children. Rotavirus test was performed on 1419 (63.3%) children. Before the introduction of universal rotavirus vaccination (2008-2010), rotavirus positivity in stool samples was 37.0%, which declined to 17.3% during the universal vaccination years (2011-2015). Overall, 1395 participants had viral AGE. Of those, 253 (18.1% [95% CI 16.1-20.2]) had unnecessary antibiotic treatment, mostly penicillin 46.6%, ceftriaxone 34.0% and azithromycin 21.7%. A multivariable analysis showed an inverse association between rotavirus vaccination and unnecessary antibiotic treatment (odds ratio = 0.53 [95% CI 0.31-0.91]), while positive associations were found with performing chest-X-ray test (3.00 [1.73-5.23]), blood (3.29 [95% CI 1.85-5.86]) and urine cultures (7.12 [3.77-13.43]), levels of C-reactive protein (1.02 [1.01-1.02]) and leukocytes (1.05 [1.01-1.09]). The results were consistent in an analysis of children with laboratory-confirmed rotavirus or norovirus AGE, or after excluding children with CRP > 50 mg/L. In conclusion, antibiotic prescription was common among hospitalized children with viral AGE, which was inversely related to rotavirus vaccination, possibly due to less severe illness in the vaccinated children.
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Affiliation(s)
- Muna Omar
- Department of Epidemiology and Preventive Medicine, School of Public Health, Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Eias Kassem
- Department of Pediatrics, Hillel Yaffe Medical Center, Hadera, Israel
| | - Emilia Anis
- Division of Epidemiology, Ministry of Health, Jerusalem, Israel
| | - Roula Abu-Jabal
- Department of Epidemiology and Preventive Medicine, School of Public Health, Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Basher Mwassi
- Department of Pediatrics, Hillel Yaffe Medical Center, Hadera, Israel
| | - Lester Shulman
- Department of Epidemiology and Preventive Medicine, School of Public Health, Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
- Central Virology Laboratory, Ministry of Health, Ramat Gan, Israel
| | - Dani Cohen
- Department of Epidemiology and Preventive Medicine, School of Public Health, Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Khitam Muhsen
- Department of Epidemiology and Preventive Medicine, School of Public Health, Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
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Soudais B, Gallais A, Schuers M. 'Male cystitis does not exist': A qualitative study of general practitioners' experiences and management of male urinary tract infections in France. Eur J Gen Pract 2024; 30:2362693. [PMID: 38881418 PMCID: PMC11185083 DOI: 10.1080/13814788.2024.2362693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 05/28/2024] [Indexed: 06/18/2024] Open
Abstract
BACKGROUND Male urinary tract infections (mUTIs) are rare in primary care. The definition of mUTIs varies across countries. The therapeutic management of mUTIs in France is based on a 14-day course of fluoroquinolones despite a high risk of antimicrobial resistance. OBJECTIVES The objective of this qualitative study was to explore general practitioners' (GPs) experiences and behaviours regarding the diagnostic and therapeutic management of mUTIs. METHODS GPs were recruited by convenience sampling in Haute Normandie (France) and interviewed individually with semi-structured guides. GPs' experiences and behaviours were recorded and analysed using an interpretive phenomenological approach. RESULTS From March 2021 to May 2022, 20 GPs were included in the study. Defining a mUTI was perceived as a diagnostic challenge. A diagnosis based on clinical evidence alone was insufficient and complementary tests were required. For GPs: 'male cystitis does not exist'. A mUTI was considered an unusual disease that could reveal an underlying condition. GPs considered fluoroquinolones to be 'potent' antibiotics and treated all patients with the same 14-day course. GPs implemented improvement strategies for antibiotic stewardship and followed the guidelines using a computerised decision support system. CONCLUSIONS GPs' experiences of mUTIs are limited due to low exposure and variable clinical presentations in primary care, representing a diagnostic and therapeutic challenge. In order to modify GPs' antibiotic prescribing behaviours, a paradigm shift in the guidelines will need to be proposed.KEY MESSAGESDefining a male urinary tract infection represents a diagnostic challenge for GPs.A diagnosis based on clinical evidence alone is insufficient and complementary tests are required.A male urinary tract infection is an unusual disease in primary care and suggests a more serious underlying condition.
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Affiliation(s)
- Benjamin Soudais
- Department of General Practice, Normandie Univ, UNIROUEN, Rouen, France
| | - Alexandre Gallais
- Department of General Practice, Normandie Univ, UNIROUEN, Rouen, France
| | - Matthieu Schuers
- Department of General Practice, Normandie Univ, UNIROUEN, Rouen, France
- Department of Biomedical Informatics, CHU Rouen, Rouen, France
- LITIS EA 4108, Normandie Univ, UNIROUEN, Rouen, France
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Ciaccio L, Fountain H, Beech E, Brown CS, Demirjian A, Gerver S, Muller-Pebody B, Bou-Antoun S. Trends in urine sampling rates of general practice patients with suspected lower urinary tract infections in England, 2015-2022: a population-based study. BMJ Open 2024; 14:e084485. [PMID: 39107033 PMCID: PMC11308898 DOI: 10.1136/bmjopen-2024-084485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 07/03/2024] [Indexed: 08/09/2024] Open
Abstract
OBJECTIVES Inappropriate prescribing of antibiotics is a key driver of antimicrobial resistance. This study aimed to describe urine sampling rates and antibiotic prescribing for patients with lower urinary tract infections (UTIs) in English general practice. DESIGN A retrospective population-based study using administrative data. SETTING IQVIA Medical Research Database (IMRD) data from general practices in England, 2015-2022. PARTICIPANTS Patients who have consulted with an uncomplicated UTI in England general practices captured in the IMRD. OUTCOME MEASURES Trends in UTI episodes (episodes were defined as UTI diagnosis codes occurring within 14 days of each other), testing and antibiotic prescribing on the same day as initial UTI consultation were assessed from January 2015 to December 2022. Associations, using univariate and multivariate logistic regressions, were examined between consultation and demographic factors on the odds of a urine test. RESULTS There were 743 350 UTI episodes; 50.8% had a urine test. Testing rates fluctuated with an upward trend and large decline in 2020. Same-day UTI antibiotic prescribing occurred in 78.2% of episodes. In multivariate modelling, factors found to decrease odds of a urine test included age ≥85 years (0.83, 95% CI 0.82 to 0.84), consultation type (remote vs face to face, 0.45, 95% CI 0.45 to 0.46), episodes in London compared with the South (0.74, 95% CI 0.72 to 0.75) and increasing practice size (0.77, 95% CI 0.76 to 0.78). Odds of urine tests increased in males (OR 1.11, 95% CI 1.10 to 1.13), for those episodes without a same-day UTI antibiotic (1.10, 95% CI 1.04 to 1.16) for episodes for those with higher deprivation status (Indices of Multiple Deprivation 8 vs 1, 1.51, 95% CI 1.48 to 1.54). Compared with 2015, 2016-2019 saw increased odds of testing while 2020 and 2021 saw decreases, with 2022 showing increased odds. CONCLUSION Urine testing for UTI in general practice in England showed an upward trend, with same-day antibiotic prescribing remaining consistent, suggesting greater alignment to national guidelines. The COVID-19 pandemic impacted testing rates, though as of 2022, they began to recover.
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Affiliation(s)
- Laura Ciaccio
- Division of Population Health and Genomics, University of Dundee School of Medicine, Dundee, UK
- Healthcare-Associated Infection (HCAI), Fungal, Antimicrobial Resistance (AMR), Antimicrobial Use (AMU) & Sepsis Division, UK Health Security Agency, London, UK
| | - Holly Fountain
- Healthcare-Associated Infection (HCAI), Fungal, Antimicrobial Resistance (AMR), Antimicrobial Use (AMU) & Sepsis Division, UK Health Security Agency, London, UK
| | | | - Colin S Brown
- Healthcare-Associated Infection (HCAI), Fungal, Antimicrobial Resistance (AMR), Antimicrobial Use (AMU) & Sepsis Division, UK Health Security Agency, London, UK
- UKHSA and NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
| | - Alicia Demirjian
- Healthcare-Associated Infection (HCAI), Fungal, Antimicrobial Resistance (AMR), Antimicrobial Use (AMU) & Sepsis Division, UK Health Security Agency, London, UK
- Department of Paediatric Infectious Diseases & Immunology, Evelina London Children's Hospital, London, UK
- Faculty of Life Sciences & Medicine, King’s College London, London, UK
| | - Sarah Gerver
- Healthcare-Associated Infection (HCAI), Fungal, Antimicrobial Resistance (AMR), Antimicrobial Use (AMU) & Sepsis Division, UK Health Security Agency, London, UK
| | - Berit Muller-Pebody
- Healthcare-Associated Infection (HCAI), Fungal, Antimicrobial Resistance (AMR), Antimicrobial Use (AMU) & Sepsis Division, UK Health Security Agency, London, UK
- UKHSA and NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
| | - Sabine Bou-Antoun
- Healthcare-Associated Infection (HCAI), Fungal, Antimicrobial Resistance (AMR), Antimicrobial Use (AMU) & Sepsis Division, UK Health Security Agency, London, UK
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Wojcik G, Afseth J, Fagan R, Thomson F, Ring N. Patient and public understanding of antimicrobial resistance: a systematic review and meta-ethnography. JAC Antimicrob Resist 2024; 6:dlae117. [PMID: 39114563 PMCID: PMC11303694 DOI: 10.1093/jacamr/dlae117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 07/05/2024] [Indexed: 08/10/2024] Open
Abstract
Objectives To further develop an understanding of laypeople's (adult patients and public) beliefs and attitudes toward antimicrobial resistance (AMR) by developing a conceptual model derived from identifying and synthesizing primary qualitative research. Methods A systematic search of 12 electronic databases, including CINAHL, MEDLINE, PsycINFO, PubMed and Web of Science to identify qualitative primary studies exploring patient and public understanding of AMR published between 2012 and 2022. Included studies were quality appraised and synthesized using Noblit and Hare's meta-ethnographic approach and reported using eMERGe guidance. Results Thirteen papers reporting 12 qualitative studies were synthesized. Studies reported data from 466 participants aged 18-90 years. Five themes were identified from these original studies: the responsible patient; when words become meaningless; patient-prescriber relationship; past experience drives antibiotic use; and reframing public perception. These themes supported the development of a conceptual model that illustrates the tension between two different assumptions, that is, how can antibiotics be used for the collective good whilst balancing the immediate needs of individual patients. Conclusions Findings suggest that AMR is a distinct ethical issue and should not be viewed purely as a prescribing problem. The meta-ethnography-generated conceptual model illustrates many factors affecting the public's perception of AMR. These include laypeople's own knowledge, beliefs and attitudes around antibiotic use, the relationship with the healthcare provider and the wider context, including the overwhelming influence of the media and public health campaigns. Future research is needed to explore effective health messaging strategies to increase laypeople's baseline awareness of AMR as a public threat.
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Affiliation(s)
- Gosha Wojcik
- School of Health and Social Care, Edinburgh Napier University, 9 Sighthill Court, Edinburgh, EH11 4BN, UK
| | - Janyne Afseth
- School of Nursing, Midwifery and Paramedic Practice, Robert Gordon University, Aberdeen, Garthdee House Garthdee Road, Aberdeen, AB10 7QG, UK
| | - Ross Fagan
- School of Health and Social Care, Edinburgh Napier University, 9 Sighthill Court, Edinburgh, EH11 4BN, UK
| | - Fiona Thomson
- School of Health and Social Care, Edinburgh Napier University, 9 Sighthill Court, Edinburgh, EH11 4BN, UK
| | - Nicola Ring
- School of Health and Social Care, Edinburgh Napier University, 9 Sighthill Court, Edinburgh, EH11 4BN, UK
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5
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Verity A, Tzortziou Brown V. GP access for inclusion health groups: perspectives and recommendations. BJGP Open 2024:BJGPO.2024.0021. [PMID: 38448086 DOI: 10.3399/bjgpo.2024.0021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 02/29/2024] [Accepted: 02/29/2024] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND General practice has seen the widespread adoption of remote consulting and triage systems. There is a lack of evidence exploring how inclusion health populations have been impacted by this transformation. AIM This study aimed to explore the post-pandemic GP access for inclusion health populations, through the lens of those with lived experience, and identify practical recommendations for improving access for this population. DESIGN & SETTING A mixed-methods study exploring the direct experience of people from inclusion health groups trying to access GP care in 13 practices in east London. METHOD A mystery shopper exercise involving 39 in-person practice visits and 13 phone calls were undertaken. The findings were reflected on by a multidisciplinary stakeholder group, which identified recommendations for improvements. RESULTS Only 31% of the mystery shopper visits (n = 8) resulted in registration and the offer of an appointment to see a GP for an urgent problem. None of the mystery shoppers was able to book an appointment over the phone but n = 10/13 felt that they would be able to register and make an appointment if they followed the receptionist's instructions. Most mystery shoppers felt respected, listened to, and understood the information provided to them. Just under half of the practices (46%, n = 6) received positive comments on how accessible and supportive their spaces felt. Practice- and system-level recommendations were identified by the stakeholder group. CONCLUSION Ongoing GP access issues persist for inclusion health populations. We identified practice- and system-level recommendations for improving access for this vulnerable population.
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Affiliation(s)
- Aaminah Verity
- Wolfson Institute of Population Health, Queen Mary University London, London, UK
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6
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Lai H, Kolanko M, Li LM, Parkinson ME, Bourke NJ, Graham NSN, David MCB, Mallas EJ, Su B, Daniels S, Wilson D, Golemme M, Norman C, Jensen K, Jackson R, Tran M, Freemont PS, Wingfield D, Wilkinson T, Gregg EW, Tzoulaki I, Sharp DJ, Soreq E. Population incidence and associated mortality of urinary tract infection in people living with dementia. J Infect 2024; 88:106167. [PMID: 38679203 DOI: 10.1016/j.jinf.2024.106167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 03/03/2024] [Accepted: 04/20/2024] [Indexed: 05/01/2024]
Abstract
OBJECTIVES Urinary tract infections (UTIs) frequently cause hospitalisation and death in people living with dementia (PLWD). We examine UTI incidence and associated mortality among PLWD relative to matched controls and people with diabetes and investigate whether delayed or withheld treatment further impacts mortality. METHODS Data were extracted for n = 2,449,814 people aged ≥ 50 in Wales from 2000-2021, with groups matched by age, sex, and multimorbidity. Poisson regression was used to estimate incidences of UTI and mortality. Cox regression was used to study the effects of treatment timing. RESULTS UTIs in dementia (HR=2.18, 95 %CI [1.88-2.53], p < .0) and diabetes (1.21[1.01-1.45], p = .035) were associated with high mortality, with the highest risk in individuals with diabetes and dementia (both) (2.83[2.40-3.34], p < .0) compared to matched individuals with neither dementia nor diabetes. 5.4 % of untreated PLWD died within 60 days of GP diagnosis-increasing to 5.9 % in PLWD with diabetes. CONCLUSIONS Incidences of UTI and associated mortality are high in PLWD, especially in those with diabetes and dementia. Delayed treatment for UTI is further associated with high mortality.
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Affiliation(s)
- Helen Lai
- UK Dementia Research Institute Care Research and Technology Centre (UK DRI CR&T) at Imperial College London and the University of Surrey, Imperial College London, White City Campus, 86 Wood Lane, London W12 0BZ, UK; Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0NN, UK
| | - Magdalena Kolanko
- UK Dementia Research Institute Care Research and Technology Centre (UK DRI CR&T) at Imperial College London and the University of Surrey, Imperial College London, White City Campus, 86 Wood Lane, London W12 0BZ, UK; Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0NN, UK
| | - Lucia M Li
- UK Dementia Research Institute Care Research and Technology Centre (UK DRI CR&T) at Imperial College London and the University of Surrey, Imperial College London, White City Campus, 86 Wood Lane, London W12 0BZ, UK; Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0NN, UK
| | - Megan E Parkinson
- UK Dementia Research Institute Care Research and Technology Centre (UK DRI CR&T) at Imperial College London and the University of Surrey, Imperial College London, White City Campus, 86 Wood Lane, London W12 0BZ, UK; Perioperative and Ageing Group, Imperial College London, South Kensington Campus, London SW7 2AZ, UK
| | - Niall J Bourke
- Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0NN, UK; Institute of Psychiatry, Psychology & Neuroscience (IoPPN), King's College London, 16 De Crespigny Park, London SE5 8AB, UK
| | - Neil S N Graham
- UK Dementia Research Institute Care Research and Technology Centre (UK DRI CR&T) at Imperial College London and the University of Surrey, Imperial College London, White City Campus, 86 Wood Lane, London W12 0BZ, UK; Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0NN, UK
| | - Michael C B David
- UK Dementia Research Institute Care Research and Technology Centre (UK DRI CR&T) at Imperial College London and the University of Surrey, Imperial College London, White City Campus, 86 Wood Lane, London W12 0BZ, UK; Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0NN, UK
| | - Emma-Jane Mallas
- UK Dementia Research Institute Care Research and Technology Centre (UK DRI CR&T) at Imperial College London and the University of Surrey, Imperial College London, White City Campus, 86 Wood Lane, London W12 0BZ, UK; Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0NN, UK
| | - Bowen Su
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, South Kensington Campus, London SW7 2AZ, UK
| | - Sarah Daniels
- UK Dementia Research Institute Care Research and Technology Centre (UK DRI CR&T) at Imperial College London and the University of Surrey, Imperial College London, White City Campus, 86 Wood Lane, London W12 0BZ, UK; Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0NN, UK
| | - Danielle Wilson
- UK Dementia Research Institute Care Research and Technology Centre (UK DRI CR&T) at Imperial College London and the University of Surrey, Imperial College London, White City Campus, 86 Wood Lane, London W12 0BZ, UK; Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0NN, UK
| | - Mara Golemme
- UK Dementia Research Institute Care Research and Technology Centre (UK DRI CR&T) at Imperial College London and the University of Surrey, Imperial College London, White City Campus, 86 Wood Lane, London W12 0BZ, UK; Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0NN, UK
| | - Claire Norman
- UK Dementia Research Institute Care Research and Technology Centre (UK DRI CR&T) at Imperial College London and the University of Surrey, Imperial College London, White City Campus, 86 Wood Lane, London W12 0BZ, UK; Brook Green Medical Centre, Hammersmith and Fulham GP Partnership, Bute Gardens, London W6 7EG, UK
| | - Kirsten Jensen
- UK Dementia Research Institute Care Research and Technology Centre (UK DRI CR&T) at Imperial College London and the University of Surrey, Imperial College London, White City Campus, 86 Wood Lane, London W12 0BZ, UK; Section of Structural and Synthetic Biology, Department of Infectious Disease, Imperial College London, School of Medicine, St Mary's Hospital, Praed Street, London W2 1NY, UK
| | - Raphaella Jackson
- UK Dementia Research Institute Care Research and Technology Centre (UK DRI CR&T) at Imperial College London and the University of Surrey, Imperial College London, White City Campus, 86 Wood Lane, London W12 0BZ, UK; Section of Structural and Synthetic Biology, Department of Infectious Disease, Imperial College London, School of Medicine, St Mary's Hospital, Praed Street, London W2 1NY, UK
| | - Martin Tran
- UK Dementia Research Institute Care Research and Technology Centre (UK DRI CR&T) at Imperial College London and the University of Surrey, Imperial College London, White City Campus, 86 Wood Lane, London W12 0BZ, UK; Section of Structural and Synthetic Biology, Department of Infectious Disease, Imperial College London, School of Medicine, St Mary's Hospital, Praed Street, London W2 1NY, UK
| | - Paul S Freemont
- UK Dementia Research Institute Care Research and Technology Centre (UK DRI CR&T) at Imperial College London and the University of Surrey, Imperial College London, White City Campus, 86 Wood Lane, London W12 0BZ, UK; Section of Structural and Synthetic Biology, Department of Infectious Disease, Imperial College London, School of Medicine, St Mary's Hospital, Praed Street, London W2 1NY, UK
| | - David Wingfield
- UK Dementia Research Institute Care Research and Technology Centre (UK DRI CR&T) at Imperial College London and the University of Surrey, Imperial College London, White City Campus, 86 Wood Lane, London W12 0BZ, UK; Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0NN, UK; Brook Green Medical Centre, Hammersmith and Fulham GP Partnership, Bute Gardens, London W6 7EG, UK
| | - Tim Wilkinson
- Centre for Clinical Brain Sciences, University of Edinburgh, 49 Little France Crescent, Edinburgh EH16 4SB, UK
| | - Edward W Gregg
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, South Kensington Campus, London SW7 2AZ, UK; School of Population Health, Royal College of Surgeons of Ireland, University of Medicine and Health Sciences, 123 St Stephen's Green, Dublin 2, Ireland
| | - Ioanna Tzoulaki
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, South Kensington Campus, London SW7 2AZ, UK; Biomedical Research Foundation Academy of Athens, 4 Soranou Ephessiou Street, Athens 115 27, Greece
| | - David J Sharp
- UK Dementia Research Institute Care Research and Technology Centre (UK DRI CR&T) at Imperial College London and the University of Surrey, Imperial College London, White City Campus, 86 Wood Lane, London W12 0BZ, UK; Department of Brain Sciences, Faculty of Medicine, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0NN, UK
| | - Eyal Soreq
- UK Dementia Research Institute Care Research and Technology Centre (UK DRI CR&T) at Imperial College London and the University of Surrey, Imperial College London, White City Campus, 86 Wood Lane, London W12 0BZ, UK.
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7
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Moragas A, Uguet P, Cots JM, Boada A, Bjerrum L, Llor C. Perception and views about individualising antibiotic duration for respiratory tract infections when patients feel better: a qualitative study with primary care professionals. BMJ Open 2024; 14:e080131. [PMID: 38316598 PMCID: PMC10860013 DOI: 10.1136/bmjopen-2023-080131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 01/12/2024] [Indexed: 02/07/2024] Open
Abstract
BACKGROUND Evidence shows a high rate of unnecessary antibiotic prescriptions for respiratory tract infections (RTIs) in primary care. There is increasing evidence showing that shorter courses for RTIs are safe and help in reducing antimicrobial resistance (AMR). Stopping antibiotics earlier, as soon as patients feel better, rather than completing antibiotic courses, may help reduce unnecessary exposure to antibiotics and AMR. OBJECTIVES The aim of this study was to explore the perceptions and views of primary care healthcare professionals about customising antibiotic duration for RTIs by asking patients to stop the antibiotic course when they feel better. DESIGN Qualitative research. SETTING AND PARTICIPANTS A total of 21 qualitative interviews with primary care professionals (experts and non-experts in AMR) were conducted from June to September 2023. Data were audiorecorded, transcribed and analysed thematically. RESULTS Overall, experts seemed more amenable to tailoring the antibiotic duration for RTIs when patients feel better. They also found the dogma of 'completing the course' to be obsolete, as evidence is changing and reducing the duration might lead to less AMR, but claimed that evidence that this strategy is as beneficial and safe as fixed courses was unambiguous. Non-experts, however, believed the dogma of completing the course. Clinicians expressed mixed views on what feeling better might mean, supporting a shared decision-making approach when appropriate. Participants claimed good communication to professionals and patients, but were sceptical about the risk of medicalisation when asking patients to contact clinicians again for a check-up visit. CONCLUSIONS Clinicians reported positive and negative views about individualising antibiotic courses for RTIs, but, in general, experts supported a customised antibiotic duration as soon as patients feel better. The information provided by this qualitative study will allow improving the performance of a large randomised clinical trial aimed at evaluating if this strategy is safe and beneficial.
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Affiliation(s)
- Ana Moragas
- Primary Healthcare Centre Jaume I, Universitat Rovira i Virgili, Tarragona, Spain
- CIBER Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
| | | | - Josep M Cots
- La Marina Health Centre, University of Barcelona, Barcelona, Spain
| | | | - Lars Bjerrum
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Carl Llor
- Department of Public Health, General Practice, University of Southern Denmark, Odense, Denmark
- CIBER Enfermedades Infecciosas, University Institute in Primary Care Research Jordi Gol, Barcelona, Spain
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8
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Omar M, Kassem E, Abu-Jabal R, Mwassi B, Cohen D, Muhsen K. Characterization of Antibiotic Treatment among Children Aged 0-59 Months Hospitalized for Acute Bacterial Gastroenteritis in Israel. Antibiotics (Basel) 2024; 13:64. [PMID: 38247623 PMCID: PMC10812600 DOI: 10.3390/antibiotics13010064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 12/22/2023] [Accepted: 01/04/2024] [Indexed: 01/23/2024] Open
Abstract
BACKGROUND We examined the extent and correlates of appropriate antibiotic use among children hospitalized with bacterial acute gastroenteritis (AGE) in Israel, a high-income country setting. METHODS Data were collected from children aged 0-59 months who participated in active hospital-based surveillance of AGE undertaken during 2007-2015. Bacterial AGE was defined as having a positive stool culture for Salmonella, Shigella, Campylobacter, or dysentery. Appropriate antibiotic use was defined as the administration of ciprofloxacin, azithromycin, or third-generation cephalosporins during hospitalization or at discharge. RESULTS Overall, 550 children had bacterial AGE; of those, 369 (67.1% [95% CI 63.1-70.9]) received antibiotics, mostly azithromycin (61.8%) and third-generation cephalosporins (37.9%). Appropriate antibiotic treatment was given to 318/550 (57.8% [95% CI 53.7-61.9]). Children aged 0-11 months vs. 24-49 months were more likely to receive appropriate antibiotic treatment (OR = 1.90 [95% CI 1.09-3.33]). Having dysentery (OR = 5.30 [95% CI 3.35-8.39]), performing blood culture (OR = 1.59 [95% CI 1.02-2.48]), and C-reactive protein (CRP) levels (OR = 1.01 [95% CI 1.01-1.02]) were positively associated with receiving appropriate antibiotic treatment. CONCLUSIONS Most children with bacterial AGE received appropriate antibiotic treatment, which correlated with young age, dysentery, CRP level, and performing blood culture, suggesting more severe illness, thus supporting the clinical decisions of physicians.
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Affiliation(s)
- Muna Omar
- Department of Epidemiology and Preventive Medicine, School of Public Health, Faculty of Medicine, Tel Aviv University, Tel Aviv 6139001, Israel; (M.O.); (R.A.-J.); (D.C.)
| | - Eias Kassem
- Department of Pediatrics, Hillel Yaffe Medical Center, Hadera 3810101, Israel; (E.K.); (B.M.)
| | - Roula Abu-Jabal
- Department of Epidemiology and Preventive Medicine, School of Public Health, Faculty of Medicine, Tel Aviv University, Tel Aviv 6139001, Israel; (M.O.); (R.A.-J.); (D.C.)
| | - Basher Mwassi
- Department of Pediatrics, Hillel Yaffe Medical Center, Hadera 3810101, Israel; (E.K.); (B.M.)
| | - Dani Cohen
- Department of Epidemiology and Preventive Medicine, School of Public Health, Faculty of Medicine, Tel Aviv University, Tel Aviv 6139001, Israel; (M.O.); (R.A.-J.); (D.C.)
| | - Khitam Muhsen
- Department of Epidemiology and Preventive Medicine, School of Public Health, Faculty of Medicine, Tel Aviv University, Tel Aviv 6139001, Israel; (M.O.); (R.A.-J.); (D.C.)
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9
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Stuart B, Venekamp R, Hounkpatin H, Wilding S, Moore M, Little P, Gulliford MC. NSAID prescribing and adverse outcomes in common infections: a population-based cohort study. BMJ Open 2024; 14:e077365. [PMID: 38171621 PMCID: PMC10773344 DOI: 10.1136/bmjopen-2023-077365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 11/19/2023] [Indexed: 01/05/2024] Open
Abstract
OBJECTIVES Infections in primary care are often treated with non-steroidal anti-inflammatory drugs (NSAIDs). This study evaluates whether NSAID prescribing is associated with adverse outcomes for respiratory (RTIs) or urinary track (UTI) infections. OBJECTIVES To determine whether there is an association between NSAID prescribing and the rate of adverse outcomes for infections for individual consulting in primary care. DESIGN Cohort study of electronic health records. SETTING 87 general practices in the UK Clinical Practice Research Datalink GOLD. PARTICIPANTS 142 925 patients consulting with RTI or UTI. PRIMARY AND SECONDARY OUTCOME MEASURES Repeat consultations, hospitalisation or death within 30 days of the initial consultation for RTI or UTI. Poisson models estimated the associations between NSAID exposure and outcome. Rate ratios were adjusted for gender, age, ethnicity, deprivation, antibiotic use, seasonal influenza vaccination status, comorbidities and general practice. Since prescribing variations by practice are not explained by case mix-hence, less impacted by confounding by indication-both individual-level and practice-level analyses are included. RESULTS There was an increase in hospital admission/death for acute NSAID prescriptions (RR 2.73, 95% CI 2.10 to 3.56) and repeated NSAID prescriptions (6.47, 4.46-9.39) in RTI patients, and for acute NSAID prescriptions for UTI (RR 3.03; 1.92 to 4.76). Practice-level analysis, controlling for practice population characteristics, found that for each percentage point increase in NSAID prescription, the percentages of hospital admission/death within 30 days increased by 0.32 percentage points (95% CI 0.16 to 0.47). CONCLUSIONS In this non-randomised study, prescription of NSAIDs at consultations for RTI or UTIs in primary care is infrequent but may be associated with increased risk of hospital admission. This supports other observational and limited trial data that NSAID prescribing might be associated with worse outcomes following acute infection and should be prescribed with caution.
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Affiliation(s)
- Beth Stuart
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
- Primary Care Research Centre, University of Southampton Faculty of Medicine, Southampton, UK
| | - Roderick Venekamp
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, Utrecht, Netherlands
| | - Hilda Hounkpatin
- Primary Care Research Centre, University of Southampton Faculty of Medicine, Southampton, UK
| | - Sam Wilding
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
| | - Michael Moore
- Primary Care Research Centre, University of Southampton Faculty of Medicine, Southampton, UK
| | - Paul Little
- Primary Care Research Centre, University of Southampton Faculty of Medicine, Southampton, UK
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10
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Kasse GE, Humphries J, Cosh SM, Islam MS. Factors contributing to the variation in antibiotic prescribing among primary health care physicians: a systematic review. BMC PRIMARY CARE 2024; 25:8. [PMID: 38166736 PMCID: PMC10759428 DOI: 10.1186/s12875-023-02223-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 11/24/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Antibiotic resistance is growing globally. The practice of health professionals when prescribing antibiotics in primary health care settings significantly impacts antibiotic resistance. Antibiotic prescription is a complex process influenced by various internal and external factors. This systematic review aims to summarize the available evidence regarding factors contributing to the variation in antibiotic prescribing among physicians in primary healthcare settings. METHODS This systematic review was conducted based on PRISMA guidelines. We included qualitative, quantitative and mixed methods studies that examined factors influencing prescription practice and variability among primary healthcare physicians. We excluded editorials, opinions, systematic reviews and studies published in languages other than English. We searched studies from electronic databases: PubMed, ProQuest Health and Medicine, Web Science, and Scopus. The quality of the included studies was appraised using the Mixed Methods Appraisal Tool (Version 2018). Narrative synthesis was employed to synthesize the result and incorporate quantitative studies. RESULTS Of the 1816 identified studies, 49 studies spanning 2000-2023 were eligible for review. The factors influencing antibiotic prescription practice and variability were grouped into physician-related, patient-related, and healthcare system-related factors. Clinical guidelines, previous patient experience, physician experience, colleagues' prescribing practice, pharmaceutical pressure, time pressure, and financial considerations were found to be influencing factors of antibiotic prescribing practice. In addition, individual practice patterns, practice volume, and relationship with patients were also other factors for the variability of antibiotic prescription, especially for intra-physician prescription variability. CONCLUSION Antibiotic prescription practice in primary health care is a complex practice, influenced by a combination of different factors and this may account for the variation. To address the factors that influence the variability of antibiotic prescription (intra- and inter-physician), interventions should aim to reduce diagnostic uncertainty and provide continuous medical education and training to promote patient-centred care.
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Affiliation(s)
- Gashaw Enbiyale Kasse
- School of Health, Faculty of Medicine and Health, University of New England, Armidale, 2351, Australia.
- Department of Clinical Medicine, College of Veterinary Medicine and Animal Science, University of Gondar, Gondar, 196, Ethiopia.
| | - Judy Humphries
- School of Health, Faculty of Medicine and Health, University of New England, Armidale, 2351, Australia
| | - Suzanne M Cosh
- School of Psychology, Faculty of Medicine and Health, University of New England, Armidale, 2351, Australia
| | - Md Shahidul Islam
- School of Health, Faculty of Medicine and Health, University of New England, Armidale, 2351, Australia
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11
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Matta M, Gantzer L, Chakvetadze C, Moussiegt A, De Pontfarcy A, Lekens B, Diamantis S. Antibiotic prescription in ambulatory care for COVID-19 patients: a cohort analysis in four European countries. Eur J Clin Microbiol Infect Dis 2024; 43:115-119. [PMID: 37980300 DOI: 10.1007/s10096-023-04716-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 11/13/2023] [Indexed: 11/20/2023]
Abstract
OBJECTIVE To analyse antibiotic prescription rates in ambulatory care for COVID-19 patients by general practitioners (GPs) in four European countries. METHODS A total of 4,513,955 anonymised electronic prescribing records of 3656 GPs in four European countries were analysed. Diagnosis and prescriptions were retrieved. Antibiotic prescription rates during COVID-19 consultations were analysed and compared between France, the UK, Belgium and Romania. RESULTS Overall prescription rate was in France and Belgium (6.66 and 7.46%). However, analysing median GP prescribing rates, we found that 33.9% of the GPs in Belgium prescribed antibiotics with a median of 16 prescriptions per 100 COVID-19 consultations, while 55.21% of the GPs in France prescribed a median of 8 antibiotic prescriptions per 100 COVID-19 consultations. Overall antibiotic prescription rates were less in Romania than in the UK (22% vs 32%); however, 73% of the Romanian GPs vs 57% of the British GPs prescribed antibiotics. Depending on the country, the proportion of each type of antibiotic was statistically different, with the proportion of azithromycin being more than 50% of all antibiotics in each country except for the UK where it was less than 1%. CONCLUSION Both individual GPs prescribing patterns in addition to overall consumption patterns should be analysed in order to implement a tailored antimicrobial stewardship programme. Furthermore, antibiotic prescribing rates in COVID-19 are lower than other respiratory tract infections.
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Affiliation(s)
- Matta Matta
- Service de Maladies Infectieuses Et Tropicales, Centre Hospitalier de Melun, Melun, France.
| | | | - Catherine Chakvetadze
- Service de Maladies Infectieuses Et Tropicales, Centre Hospitalier de Melun, Melun, France
| | - Aurore Moussiegt
- Service de Maladies Infectieuses Et Tropicales, Centre Hospitalier de Melun, Melun, France
| | - Astrid De Pontfarcy
- Service de Maladies Infectieuses Et Tropicales, Centre Hospitalier de Melun, Melun, France
| | | | - Sylvain Diamantis
- Service de Maladies Infectieuses Et Tropicales, Centre Hospitalier de Melun, Melun, France
- Dynamic Research Unit, Université Paris Est Créteil, Créteil, France
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12
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Kaur A, Mott DA, Gilson A. Tracking changes in opioid prescriptions dispensed following the enactment of a prescription drug monitoring program use mandate. Res Social Adm Pharm 2023; 19:1543-1550. [PMID: 37716901 DOI: 10.1016/j.sapharm.2023.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 07/21/2023] [Accepted: 08/16/2023] [Indexed: 09/18/2023]
Abstract
BACKGROUND Prescription drug monitoring programs (PDMPs) are state-based surveillance tools used to track controlled substances dispensed to patients and identify patients at-risk of misuse. Starting April 2017, Wisconsin required all prescribers access PDMP to review patient information before issuing a controlled substance prescription order for more than a 3-day supply. A primary goal of PDMP use mandates is to reduce avoidable prescribing and mitigate opioid related mortality and morbidity. Current literature has not evaluated the existence of a time point post-policy implementation, at which the trend in opioid dispensing changes, reflecting normalization/maintenance of opioid prescribing. OBJECTIVE We sought to evaluate the impact of the PDMP use mandate on trends in opioid prescriptions dispensed and test a hypothesis that a change or inflection in opioid prescriptions dispensed occurred post-mandate implementation. METHODS Interrupted Time Series Analysis (ITSA) design was used to examine whether the level (immediate impact) and trend in opioid prescribing changed significantly after the PDMP use mandate was implemented. We used a novel Change Point Analysis (CPA) approach to test the hypothesis i.e., identify if and when a change or inflection in opioid dispensing trend occurred after implementation of the PDMP use mandate. RESULTS ITSA model results showed a significant drop in opioid prescriptions dispensed (p < 0.05) immediately after the mandate implementation (i.e., April 2017). Results of the CPA identified a significant inflection in opioid prescriptions dispensed starting January 2019 (21-months post-policy implementation). An ITSA model using the inflection point as an interruption showed that the trend in opioid prescriptions dispensed became flatter after the inflection point, suggesting normalization. CONCLUSION Using a novel CPA approach, the findings showed an inflection in the trend in opioid prescriptions dispensed post-PDMP use mandate implementation, implying that most of the avoidable prescribing likely was curtailed. The results suggest that the patient information presumably accessed from the WI PDMP interface was useful in helping prescribers to make an informed clinical decision about opioid prescribing.
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Affiliation(s)
- Arveen Kaur
- Social and Administrative Sciences Division, University of Wisconsin-Madison, School of Pharmacy, 777 Highland Ave, Rennebohm Hall, Madison, WI, 53705, USA.
| | - David A Mott
- Social and Administrative Sciences Division, School of Pharmacy, University of Wisconsin-Madison, 777 Highland Ave, 2509 Rennebohm Hall, Madison, WI, 53705, USA.
| | - Aaron Gilson
- Social and Administrative Sciences Division, School of Pharmacy, University of Wisconsin-Madison, 777 Highland Ave, 2527D Rennebohm Hall, Madison, WI, 53705, USA.
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Wushouer H, Du K, Chen S, Li H, Zhang W, Yang Y, Hu L, Zhou Y, Sun H, Zheng B, Guan X, Shi L. Evaluation of prescription review and feedback policy on rational antibiotic use in primary healthcare settings in Beijing, China: a qualitative study using the Theoretical Domains Framework and the behaviour change wheel. JAC Antimicrob Resist 2023; 5:dlad128. [PMID: 38046566 PMCID: PMC10691747 DOI: 10.1093/jacamr/dlad128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 11/14/2023] [Indexed: 12/05/2023] Open
Abstract
Objectives To decelerate antibiotic resistance driven by inappropriate antibiotic prescribing, a prescription review and feedback (PRF) policy is implemented in primary healthcare institutions (PHIs) in Beijing, China. However, evaluation of PRF implementation in PHIs is scarce. This study aims to systematically identify the barriers and facilitators of PRF policy implementation to provide evidence for antimicrobial stewardship. Methods We conducted key informant interviews with 40 stakeholders engaged in the implementation of PRF in Beijing, including physicians, pharmacists and administrators. Interviews were audio recorded and transcribed verbatim. We coded the interview transcripts and mapped informant views to domains of the Theoretical Domains Framework. We then used a behaviour change wheel to suggest possible behavioural interventions. Results Procedural knowledge (Knowledge) and skills (Skill) of PRF were possessed by stakeholders. They felt responsible to promote the appropriate use of antibiotics (Social/professional role and identity) and believed that PRF could help to change inappropriate provider behaviours (Behavioural regulation) in prescribing antibiotics (Beliefs about consequences) under increased intention on antibiotic use (Stages of change). Moreover, informants called for a more unified review standard to enhance PRF implementation (Goals). Frequently identified barriers to PRF included inadequate capacity (Skill), using punishment mechanism (Behaviour regulation), reaching consistently lower antibiotic prescription rates (Goals), lack of resources (Environmental context and resources) and perceived pressure coming from patients (Social influences). Conclusions Stakeholders believed that PRF implementation promoted the rational use of antibiotics at PHIs in Beijing. Still, PRF was hampered by inconsistencies in review process and resources needed for PRF implementation.
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Affiliation(s)
- Haishaerjiang Wushouer
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, 38 Xueyuan Road, Haidian District, Beijing 100191, China
- International Research Center for Medicinal Administration, Peking University, Beijing 100191, China
| | - Kexin Du
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, 38 Xueyuan Road, Haidian District, Beijing 100191, China
| | - Shicai Chen
- Department of Clinical Pharmacology, National Institute on Drug Dependence, Peking University, Beijing 100191, China
| | - Huangqianyu Li
- International Research Center for Medicinal Administration, Peking University, Beijing 100191, China
| | - Wanmeng Zhang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, 38 Xueyuan Road, Haidian District, Beijing 100191, China
| | - Yaoyao Yang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, 38 Xueyuan Road, Haidian District, Beijing 100191, China
| | - Lin Hu
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, 38 Xueyuan Road, Haidian District, Beijing 100191, China
| | - Yue Zhou
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, 38 Xueyuan Road, Haidian District, Beijing 100191, China
- Department of Pharmacy, Peking University People’s Hospital, Beijing 100044, China
| | - Hui Sun
- United Nations Children’s Fund, China Office, Beijing 100600, China
| | - Bo Zheng
- Institute of Clinical Pharmacology, Peking University First Hospital, Beijing 100034, China
| | - Xiaodong Guan
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, 38 Xueyuan Road, Haidian District, Beijing 100191, China
- International Research Center for Medicinal Administration, Peking University, Beijing 100191, China
| | - Luwen Shi
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, 38 Xueyuan Road, Haidian District, Beijing 100191, China
- International Research Center for Medicinal Administration, Peking University, Beijing 100191, China
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14
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Vestesson E, De Corte K, Chappell P, Crellin E, Clarke GM. Antibiotic prescribing in remote versus face-to-face consultations for acute respiratory infections in primary care in England: an observational study using target maximum likelihood estimation. EClinicalMedicine 2023; 64:102245. [PMID: 37842171 PMCID: PMC10568332 DOI: 10.1016/j.eclinm.2023.102245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 08/28/2023] [Accepted: 09/13/2023] [Indexed: 10/17/2023] Open
Abstract
Background The COVID-19 pandemic has led to an ongoing increase in the use of remote consultations in general practice in England. Although the evidence is limited, there are concerns that the increase in remote consultations could lead to more antibiotic prescribing. Methods In this cohort study, we used patient-level primary care data from the Clinical Practice Research Datalink to estimate the association between consultation mode (remote versus face-to-face) and antibiotic prescribing in England for acute respiratory infections (ARI) between April 2021 and March 2022. Eligibility criteria were applied at both practice-level and patient-level. 400 practices in England were sampled at random and then 600,000 patients were randomly sampled from the eligible patients (whose sex was recorded). Consultations for acute respiratory infections were identified. All antibiotic prescriptions were included, with the exception of antituberculosis drugs and antileprotic drugs, as identified through chapter 5.1 of the British National Formulary. The CPRD Aurum data was linked to the COVID-19 ONS infection survey by region. All analyses were done at the individual level. Repeated consultations from the same patient within 7 days were grouped together. We used targeted maximum likelihood estimation, a causal machine learning method with adjustment for infection type and patient-level, clinician-level and practice-level factors. Findings There were 45,997 ARI consultations (34,555 unique patients) within the study period, of which 28,127 were remote and 17,870 were face-to-face. For children, 48% of consultations were remote and, for adults, 66% were remote. For children, 42% of remote and 43% of face-to-face consultations led to an antibiotic prescription; the equivalent values for adults were 52% and 42%, respectively. After adjustment with TMLE, adults with a remote consultation had 23% (odds ratio [OR] 1.23, 95% CI: 1.18-1.29) higher chance of being prescribed antibiotics than if they had been seen face-to-face. We found no significant association between consultation mode and antibiotic prescribing in children (OR 1.04 95% CI: 0.98-1.11). Interpretation The higher rates of antibiotic prescribing in remote consultations for adults are cause for concern. We see no significant difference in antibiotic prescribing between consultation mode for children. These findings should inform antimicrobial stewardship activities for health-care professionals and policy makers. Future research should examine differences in guideline-compliance between remote and face-to-face consultations to understand the factors driving antibiotic prescribing in different consultation modes. Funding None.
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Affiliation(s)
- Emma Vestesson
- The Health Foundation, London, UK
- University College London Great Ormond Street Institute of Child Health, London, UK
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15
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Finnikin SJ, Wilcock J, Edwards PJ. Presentation and management of insect bites in out-of-hours primary care: a descriptive study. BMJ Open 2023; 13:e070636. [PMID: 37709307 PMCID: PMC10503338 DOI: 10.1136/bmjopen-2022-070636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 08/30/2023] [Indexed: 09/16/2023] Open
Abstract
OBJECTIVES To describe the population presenting to out-of-hours primary care with insect bites, establish their clinical management and the factors associated with antibiotic prescribing. DESIGN An observational study using routinely collected data from a large out-of-hours database (BORD, Birmingham Out-of-hours general practice Research Database). SETTING A large out-of-hour primary care provider in the Midlands region of England. PARTICIPANTS All patients presenting with insect bites between July 2013 and February 2020 were included comprising 5774 encounters. OUTCOME MEASURES This cohort was described, and a random subcohort was created for more detailed analysis which established the clinical features of the presenting insect bites. Logistic regression was used to model variables associated with antibiotic prescribing. RESULTS Of the 5641 encounters solely due to insect bites, 67.1% (95% CI 65.8% to 68.3%) were prescribed antibiotics. General practitioners were less likely to prescribe antibiotics than advanced nurse practitioners (60.5% vs 71.1%, p<0.001) and there was a decreasing trend in antibiotic prescribing as patient deprivation increased. Pain (OR 2.13, 95% CI 1.18 to 3.86), swelling (OR 2.88, 95% CI 1.52 to 5.46) and signs of spreading (OR 3.45, 95% CI 1.54 to 7.70) were associated with an increased frequency of antibiotic prescribing. Extrapolation of the findings give an estimated incidence of insect bite consultations in England of 1.5 million annually. CONCLUSION Two-thirds of the patients presenting to out-of-hours primary care with insect bites receive antibiotics. While some predictors of prescribing have been found, more research is required to understand the optimal use of antibiotics for this common presentation.
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Affiliation(s)
| | - Jane Wilcock
- Silverdale Medical Practice, Pendlebury Health Centre, Salford, UK
| | - Peter Jonathan Edwards
- Institute for Applied Health Research, University of Birmingham, Birmingham, UK
- Centre for Academic Primary Care, Bristol Medical School, Bristol, UK
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16
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Whittaker H, Nordon C, Rubino A, Morris T, Xu Y, De Nigris E, Müllerová H, Quint JK. Frequency and severity of respiratory infections prior to COPD diagnosis and risk of subsequent postdiagnosis COPD exacerbations and mortality: EXACOS-UK health care data study. Thorax 2023; 78:760-766. [PMID: 36316117 PMCID: PMC10359568 DOI: 10.1136/thorax-2022-219039] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 09/10/2022] [Indexed: 03/08/2023]
Abstract
OBJECTIVE Little is known about how lower respiratory tract infections (LRTIs) before chronic obstructive pulmonary disease (COPD) are associated with future exacerbations and mortality. We investigated this association in patients with COPD in England. METHODS Clinical Practice Research Datalink Aurum, Hospital Episode Statistics and Office of National Statistics data were used. Start of follow-up was patient's first ever COPD diagnosis date and a 1-year baseline period prior to start of follow-up was used to find mild LRTIs (general practice (GP) events/no antibiotics), moderate LRTIs (GP events+antibiotics) and severe LRTIs (hospitalised). Patients were categorised as having: none, 1 mild only, 2+ mild only, 1 moderate, 2+ moderate and 1+ severe. Negative binomial regression modelled the association between baseline LRTIs and subsequent COPD exacerbations and Cox proportional hazard regression was used to investigate mortality. RESULTS In 215 234 patients with COPD, increasing frequency and severity of mild and moderate LRTIs were associated with increased rates of subsequent exacerbations compared with no recorded LRTIs (1 mild adjusted IRR 1.16, 95% CI 1.14 to 1.18, 2+ mild IRR 1.51, 95% CI 1.46 to 1.55, 1 moderate IRR 1.81, 95% CI 1.78 to 1.85, 2+ moderate IRR 2.55, 95% CI 2.48 to 2.63). Patients with 1+ severe LRTI (vs no baseline LRTIs) also showed an increased rate of future exacerbations (adjusted IRR 1.75, 95% CI, 1.70 to 1.80). This pattern of association was similar for risk of all-cause and COPD-related mortality; however, patients with 1+ severe LRTIs had the highest risk of all-cause and COPD mortality. CONCLUSION Increasing frequency and severity of LRTIs prior to COPD diagnosis were associated with increasing rates of subsequent exacerbations, and increasing risk of all-cause and COPD-related mortality.
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Affiliation(s)
- Hannah Whittaker
- National Heart and Lung Institute, Imperial College London, London, UK
| | | | | | - Tamsin Morris
- Medical and Scientific Affairs, AstraZeneca, Luton, UK
| | - Yang Xu
- Medical and Scientific Affairs, AstraZeneca, Luton, UK
| | | | | | - Jennifer K Quint
- National Heart and Lung Institute, Imperial College London, London, UK
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van Heuvel L, Paget J, Dückers M, Caini S. The impact of influenza and pneumococcal vaccination on antibiotic use: an updated systematic review and meta-analysis. Antimicrob Resist Infect Control 2023; 12:70. [PMID: 37452389 PMCID: PMC10347879 DOI: 10.1186/s13756-023-01272-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 07/04/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND Vaccination can prevent bacterial and viral infections that could otherwise increase the chances of receiving (unnecessary) antibiotic treatment(s). As a result, vaccination may provide an important public health intervention to control antimicrobial resistance (AMR). OBJECTIVES Perform a systematic literature review to better understand the impact of influenza, pneumococcal and COVID-19 vaccination on antibiotic use, and to identify differences in effect between world regions and study designs. METHODS We performed a systematic literature review and meta-analysis which updated previous literature reviews with new data from 1 October 2018 to 1 December 2021. The study focuses on randomised controlled trials (RCTs) and observational studies. Results from the meta-analysis of RCTs were stratified by WHO region and age group. Vote counting based on the direction of effect was applied to synthesize the results of the observational studies. RESULTS Most studies are performed in the WHO European Region and the Region of the Americas in high-income countries. RCTs show that the effect of influenza vaccination on the number of antibiotic prescriptions or days of antibiotic use (Ratio of Means (RoM) 0.71, 95% CI 0.62-0.83) is stronger compared to the effect of pneumococcal vaccination (RoM 0.92, 95% CI 0.85-1.00). These studies also confirm a reduction in the proportion of people receiving antibiotics after influenza vaccination (Risk Ratio (RR) 0.63, 95% CI 0.51-0.79). The effect of influenza vaccination in the European and American regions ranged from RoM 0.63 and 0.87 to RR 0.70 and 0.66, respectively. The evidence from observational studies supports these findings but presents a less consistent picture. No COVID-19 studies were identified. CONCLUSION We find that both RCTs and observational studies show that influenza vaccination significantly reduces antibiotic use, while the effect of pneumococcal vaccination is less pronounced. We were unable to study the effect of COVID-19 vaccination and no clear regional patterns were found due to the high heterogeneity between studies. Overall, our data supports the use of influenza vaccination as an important public health intervention to reduce antibiotic use and possibly control AMR.
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Affiliation(s)
- Lotte van Heuvel
- Netherlands Institute for Health Services Research (Nivel), Otterstraat 118, 3513 CR, Utrecht, The Netherlands
| | - John Paget
- Netherlands Institute for Health Services Research (Nivel), Otterstraat 118, 3513 CR, Utrecht, The Netherlands.
| | - Michel Dückers
- Netherlands Institute for Health Services Research (Nivel), Otterstraat 118, 3513 CR, Utrecht, The Netherlands
- ARQ Centre of Expertise for the Impact of Disasters and Crises, Diemen, The Netherlands
- Faculty of Behavioural and Social Sciences, University of Groningen, Groningen, The Netherlands
| | - Saverio Caini
- Netherlands Institute for Health Services Research (Nivel), Otterstraat 118, 3513 CR, Utrecht, The Netherlands
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18
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Poluektova O, Robertson DA, Rafferty A, Cunney R, Lunn PD. A scoping review and behavioural analysis of factors underlying overuse of antimicrobials. JAC Antimicrob Resist 2023; 5:dlad043. [PMID: 37168837 PMCID: PMC10164659 DOI: 10.1093/jacamr/dlad043] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 03/14/2023] [Indexed: 05/13/2023] Open
Abstract
Background Overuse of antimicrobials is a challenging global issue that contributes to antimicrobial resistance. Despite widespread awareness of the problem among members of the medical community and various attempts to improve prescription practices, existing antimicrobial stewardship programmes are not always effective. In our view, this may reflect limited understanding of factors that influence prescription of antimicrobials as empirical therapy, implying a need to address the psychological mechanisms behind some of the specific behaviours involved. Objectives To identify factors that influence the antimicrobials prescription as empirical therapy, and to relate these factors to findings from behavioural science. Methods We conducted a scoping review of the literature on the factors underlying antimicrobial prescription decisions, following the protocol designed using PRISMA guidelines. Results and conclusions From a final sample of 90 sources, we identified ten factors important in antimicrobial prescription decisions. In the second stage of our analysis, we grouped them into five final categories: (1) nature of the decision, (2) social influences, (3) individual differences, (4) characteristics of the patient, (5) context. We analyse these categories using a behavioural science perspective.
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Affiliation(s)
| | - Deirdre A Robertson
- Behavioural Research Unit, The Economic and Social Research Institute, Whitaker Square, Sir John Rogerson’s Quay, Ireland
- Trinity College Dublin, School of Psychology, Dublin, Ireland
| | - Aisling Rafferty
- Children’s Health Ireland, Department of Pharmacy, Dublin, Ireland
- University of Birmingham, School of Pharmacy, Institute of Clinical Sciences,Birmingham, UK
| | - Robert Cunney
- Children’s Health Ireland, Irish Meningitis and Sepsis Reference Laboratory, Dublin, Ireland
- Royal College of Surgeons in Ireland, Department of Microbiology, Dublin, Ireland
- Children’s Health Ireland, Department of Microbiology, Dublin, Ireland
| | - Peter D Lunn
- Behavioural Research Unit, The Economic and Social Research Institute, Whitaker Square, Sir John Rogerson’s Quay, Ireland
- Trinity College Dublin, Department of Economics, Dublin, Ireland
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Koh SWC, Lee VME, Low SH, Tan WZ, Valderas JM, Loh VWK, Sundram M, Hsu LY. Prescribing Antibiotics in Public Primary Care Clinics in Singapore: A Retrospective Cohort Study. Antibiotics (Basel) 2023; 12:antibiotics12040762. [PMID: 37107127 PMCID: PMC10135213 DOI: 10.3390/antibiotics12040762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/11/2023] [Accepted: 04/14/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Antibiotic prescription practices in primary care in Singapore have received little scholarly attention. In this study, we ascertained prescription prevalence and identified care gaps and predisposing factors. METHODS A retrospective study was conducted on adults (>21 years old) at six public primary care clinics in Singapore. Prescriptions >14 days were excluded. Descriptive statistics were used to showcase the prevalence data. We used chi-square and logistic regression analyses to identify the factors affecting care gaps. RESULTS A total of 141,944 (4.33%) oral and 108,357 (3.31%) topical antibiotics were prescribed for 3,278,562 visits from 2018 to 2021. There was a significant reduction in prescriptions (p < 0.01) before and after the pandemic, which was attributed to the 84% reduction in prescriptions for respiratory conditions. In 2020 to 2021, oral antibiotics were most prescribed for skin (37.7%), genitourinary (20.2%), and respiratory conditions (10.8%). Antibiotic use in the "Access" group (WHO AWaRe classification) improved from 85.6% (2018) to 92.1% (2021). Areas of improvement included a lack of documentation of reasons for antibiotic use, as well as inappropriate antibiotic prescription for skin conditions. CONCLUSION There was a marked reduction in antibiotic prescriptions associated with the onset of the COVID-19 pandemic. Further studies could address the gaps identified here and evaluate private-sector primary care to inform antibiotic guidelines and the local development of stewardship programs.
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Affiliation(s)
- Sky Wei Chee Koh
- National University Polyclinics, National University Health System, Singapore 609606, Singapore
- Division of Family Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
| | - Vivien Min Er Lee
- National University Polyclinics, National University Health System, Singapore 609606, Singapore
- Division of Family Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
| | - Si Hui Low
- National University Polyclinics, National University Health System, Singapore 609606, Singapore
| | - Wei Zhi Tan
- National University Polyclinics, National University Health System, Singapore 609606, Singapore
- School of Biological Sciences, Nanyang Technological University, Singapore 637551, Singapore
| | - José María Valderas
- Division of Family Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
| | - Victor Weng Keong Loh
- Division of Family Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
| | - Meena Sundram
- National University Polyclinics, National University Health System, Singapore 609606, Singapore
| | - Li Yang Hsu
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore 117549, Singapore
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20
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Hurley R, Jury F, van Staa TP, Palin V, Armitage CJ. Clinician acceptability of an antibiotic prescribing knowledge support system for primary care: a mixed-method evaluation of features and context. BMC Health Serv Res 2023; 23:367. [PMID: 37060063 PMCID: PMC10103677 DOI: 10.1186/s12913-023-09239-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 03/02/2023] [Indexed: 04/16/2023] Open
Abstract
BACKGROUND Overprescribing of antibiotics is a major concern as it contributes to antimicrobial resistance. Research has found highly variable antibiotic prescribing in (UK) primary care, and to support more effective stewardship, the BRIT Project (Building Rapid Interventions to optimise prescribing) is implementing an eHealth Knowledge Support System. This will provide unique individualised analytics information to clinicians and patients at the point of care. The objective of the current study was to gauge the acceptability of the system to prescribing healthcare professionals and highlight factors to maximise intervention uptake. METHODS Two mixed-method co-design workshops were held online with primary care prescribing healthcare professionals (n = 16). Usefulness ratings of example features were collected using online polls and online whiteboards. Verbal discussion and textual comments were analysed thematically using inductive (participant-centred) and deductive perspectives (using the Theoretical Framework of Acceptability). RESULTS Hierarchical thematic coding generated three overarching themes relevant to intervention use and development. Clinician concerns (focal issues) were safe prescribing, accessible information, autonomy, avoiding duplication, technical issues and time. Requirements were ease and efficiency of use, integration of systems, patient-centeredness, personalisation, and training. Important features of the system included extraction of pertinent information from patient records (such as antibiotic prescribing history), recommended actions, personalised treatment, risk indicators and electronic patient communication leaflets. Anticipated acceptability and intention to use the knowledge support system was moderate to high. Time was identified as a focal cost/ burden, but this would be outweighed if the system improved patient outcomes and increased prescribing confidence. CONCLUSION Clinicians anticipate that an eHealth knowledge support system will be a useful and acceptable way to optimise antibiotic prescribing at the point of care. The mixed method workshop highlighted issues to assist person-centred eHealth intervention development, such as the value of communicating patient outcomes. Important features were identified including the ability to efficiently extract and summarise pertinent information from the patient records, provide explainable and transparent risk information, and personalised information to support patient communication. The Theoretical Framework of Acceptability enabled structured, theoretically sound feedback and creation of a profile to benchmark future evaluations. This may encourage a consistent user-focused approach to guide future eHealth intervention development.
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Affiliation(s)
- Ruth Hurley
- Manchester Centre for Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK.
| | - Francine Jury
- Centre for Health Informatics, Division of Informatics, Imaging and Data Science, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Tjeerd P van Staa
- Centre for Health Informatics, Division of Informatics, Imaging and Data Science, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Victoria Palin
- Centre for Health Informatics, Division of Informatics, Imaging and Data Science, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Christopher J Armitage
- Manchester Centre for Health Psychology, Faculty of Biology, Medicine and Health, Division of Psychology and Mental Health, School of Health Sciences, The University of Manchester, Manchester, UK
- Academic Health Science Centre, Manchester University NHS Foundation Trust (MFT), NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester, Manchester, UK
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21
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Schramm L, Byrne MK, Sweetnam T. Antibiotic Misuse Behaviours of Older People: Confirmation of the Factor Structure of the Antibiotic Use Questionnaire. Antibiotics (Basel) 2023; 12:antibiotics12040718. [PMID: 37107080 PMCID: PMC10135189 DOI: 10.3390/antibiotics12040718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 03/22/2023] [Accepted: 03/28/2023] [Indexed: 04/29/2023] Open
Abstract
Antibacterial resistance (AR) is responsible for steadily rising numbers of untreatable bacterial infections, most prevalently found in the older adult (OA) population due to age-related physical and cognitive deterioration, more frequent and long-lasting hospital visits, and reduced immunity. There are currently no established measures of antibiotic use behaviours for older adults, and theory-informed approaches to identifying the drivers of antibiotic use in older adults are lacking in the literature. The objective of this study was to identify predictors of antibiotic use and misuse in older adults using the Antibiotic Use Questionnaire (AUQ), a measure informed by the factors of the Theory of Planned Behaviour (TPB): attitudes and beliefs, social norms, perceived behavioural control, behaviour, and a covariate-knowledge. A measure of social desirability was included, and participants scoring highly were excluded to control for social desirability bias. Confirmatory Factor Analyses and regression analyses were conducted to test the hypotheses in a cross-sectional, anonymous survey. A total of 211 participants completed the survey, 47 of which were excluded due to incompletion and high social desirability scores (≥5). Results of the factor analysis confirmed that some (but not all) factors from previous research in the general population were confirmed in the OA sample. No factors were found to be significant predictors of antibiotic use behaviour. Several suggestions for the variance in results from that of the first study are suggested, including challenges with meeting requirement for statistical power. The paper concludes that further research is required to determine the validity of the AUQ in an older adult population.
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Affiliation(s)
- Loni Schramm
- Faculty of Health, Charles Darwin University, Darwin, NT 0909, Australia
| | - Mitchell K Byrne
- Faculty of Health, Charles Darwin University, Darwin, NT 0909, Australia
| | - Taylor Sweetnam
- Faculty of Health, Charles Darwin University, Darwin, NT 0909, Australia
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22
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White B, Renzi C, Barclay M, Lyratzopoulos G. Underlying cancer risk among patients with fatigue and other vague symptoms: a population-based cohort study in primary care. Br J Gen Pract 2023; 73:e75-e87. [PMID: 36702593 PMCID: PMC9888575 DOI: 10.3399/bjgp.2022.0371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 10/17/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Presenting to primary care with fatigue is associated with slightly increased cancer risk, although it is unknown how this varies in the presence of other 'vague' symptoms. AIM To quantify cancer risk in patients with fatigue who present with other 'vague' symptoms in the absence of 'alarm' symptoms for cancer. DESIGN AND SETTING Cohort study of patients presenting in UK primary care with new-onset fatigue during 2007-2015, using Clinical Practice Research Datalink data linked to national cancer registration data. METHOD Patients presenting with fatigue without co-occurring alarm symptoms or anaemia were identified, who were further characterised as having co-occurrence of 19 other 'vague' potential cancer symptoms. Sex- and age-specific 9-month cancer risk for each fatigue-vague symptom cohort were calculated. RESULTS Of 285 382 patients presenting with new-onset fatigue, 84% (n = 239 846) did not have co-occurring alarm symptoms or anaemia. Of these, 38% (n = 90 828) presented with ≥1 of 19 vague symptoms for cancer. Cancer risk exceeded 3% in older males with fatigue combined with any of the vague symptoms studied. The age at which risk exceeded 3% was 59 years for fatigue-weight loss, 65 years for fatigue-abdominal pain, 67 years for fatigue-constipation, and 67 years for fatigue-other upper gastrointestinal symptoms. For females, risk exceeded 3% only in older patients with fatigue-weight loss (from 65 years), fatigue-abdominal pain (from 79 years), or fatigue-abdominal bloating (from 80 years). CONCLUSION In the absence of alarm symptoms or anaemia, fatigue combined with specific vague presenting symptoms, alongside patient age and sex, can guide clinical decisions about referral for suspected cancer.
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Affiliation(s)
- Becky White
- Epidemiology of Cancer Healthcare and Outcomes (ECHO) Research Group, Department of Behavioural Science and Health, University College London, UK
| | - Cristina Renzi
- Epidemiology of Cancer Healthcare and Outcomes (ECHO) Research Group, Department of Behavioural Science and Health, University College London, UK, and associate professor, Faculty of Medicine, University Vita-Salute San Raffaele, Milan, Italy
| | - Matthew Barclay
- Epidemiology of Cancer Healthcare and Outcomes (ECHO) Research Group, Department of Behavioural Science and Health, University College London, UK
| | - Georgios Lyratzopoulos
- Epidemiology of Cancer Healthcare and Outcomes (ECHO) Research Group, Department of Behavioural Science and Health, University College London, UK
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Stewart EJ. Delayed antibiotic prescription did not delay recovery in children with respiratory tract infections. Arch Dis Child Educ Pract Ed 2023; 108:53. [PMID: 34413123 DOI: 10.1136/archdischild-2021-322607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Psychological and cultural factors influencing antibiotic prescription. Trends Microbiol 2023; 31:559-570. [PMID: 36720668 DOI: 10.1016/j.tim.2022.12.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 12/21/2022] [Accepted: 12/30/2022] [Indexed: 01/31/2023]
Abstract
Humans have inundated the environment worldwide with antimicrobials for about one century, giving selective advantage to antibiotic-resistant bacteria. Therefore, antibiotic resistance has become a public health problem responsible for increased mortality and extended hospital stays because the efficacy of antibiotics has diminished. Hospitals and other clinical settings have implemented stewardship measures to reduce antibiotic administration and prescription. However, these measures demand multifactorial approaches, including multidisciplinary teams in clinical settings and the education of professionals and patients. Recent studies indicate that individual factors, such as mother-infant attachment and parenting styles, play a critical role in antibiotic use. Also, macrocontextual factors, such as economic, social, or cultural backgrounds, may impact antibiotic use rates. Therefore, research aiming to ameliorate stewardship measures must include psychologically and sociologically based research.
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25
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Abuhammad S, Ababneh H. Nurses’ knowledge, motivation, behaviors, and information sources on antibiotic use and resistance in Jordan. ELECTRONIC JOURNAL OF GENERAL MEDICINE 2023. [DOI: 10.29333/ejgm/12571] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
<b>Aim:</b> This study aims to examine the nurse knowledge, motivation, and behavior about antibiotics and antibiotic resistance. A secondary objective was to study the preferred information sources used by Jordanian nurses, as well as their knowledge of the information available to promote rational prescription practices in the Jordanian health system.<b> </b><br />
<b>Method: </b>The study was cross-sectional in design and nurses (n=1,093) completed an online survey using Google Forms. Participation in the study was completely optional, and participants were free to drop out at any point. During the months of February-May 2022, nurses were asked to participate in a survey<br />
<b>Results:</b> The study found 48.2% of nurses given prescribed antibiotics to the patients daily or multiple times a day in the preceding week; 13.3% of nurses provided support on daily or more frequent antibacterial drugs use or infection management. The reason for not giving advice regarding antibiotics were no leaflet regarding the use of the antibiotics (42.3%) and the patients do not get attention for the information (30.4%).<br />
<b>Conclusion:</b> In conclusion, the findings of this study show that public health actions are needed (e.g., educational or communication campaigns). Nurses must be educated on the proper use of antibiotics and the emergence of antibiotic resistance. Antibiotic stewardship can benefit from the findings, which can be used to develop interventions aimed at improving antibiotic usage.
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Affiliation(s)
- Sawsan Abuhammad
- Department of Maternal and Child Health, Faculty of Nursing, Jordan University of Science and Technology, Irbid, JORDAN
| | - Hamza Ababneh
- Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, JORDAN
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Van Staa T, Li Y, Gold N, Chadborn T, Welfare W, Palin V, Ashcroft DM, Bircher J. Comparing antibiotic prescribing between clinicians in UK primary care: an analysis in a cohort study of eight different measures of antibiotic prescribing. BMJ Qual Saf 2022; 31:831-838. [PMID: 35241573 PMCID: PMC9606525 DOI: 10.1136/bmjqs-2020-012108] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 02/02/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND There is a need to reduce antimicrobial uses in humans. Previous studies have found variations in antibiotic (AB) prescribing between practices in primary care. This study assessed variability of AB prescribing between clinicians. METHODS Clinical Practice Research Datalink, which collects electronic health records in primary care, was used to select anonymised clinicians providing 500+ consultations during 2012-2017. Eight measures of AB prescribing were assessed, such as overall and incidental AB prescribing, repeat AB courses and extent of risk-based prescribing. Poisson regression models with random effect for clinicians were fitted. RESULTS 6111 clinicians from 466 general practices were included. Considerable variability between individual clinicians was found for most AB measures. For example, the rate of AB prescribing varied between 77.4 and 350.3 per 1000 consultations; percentage of repeat AB courses within 30 days ranged from 13.1% to 34.3%; predicted patient risk of hospital admission for infection-related complications in those prescribed AB ranged from 0.03% to 0.32% (5th and 95th percentiles). The adjusted relative rate between clinicians in rates of AB prescribing was 5.23. Weak correlation coefficients (<0.5) were found between most AB measures. There was considerable variability in case mix seen by clinicians. The largest potential impact to reduce AB prescribing could be around encouraging risk-based prescribing and addressing repeat issues of ABs. Reduction of repeat AB courses to prescribing habit of median clinician would save 21 813 AB prescriptions per 1000 clinicians per year. CONCLUSIONS The wide variation seen in all measures of AB prescribing and weak correlation between them suggests that a single AB measure, such as prescribing rate, is not sufficient to underpin the optimisation of AB prescribing.
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Affiliation(s)
- Tjeerd Van Staa
- Division of Informatics, Imaging & Data Sciences, University of Manchester, Manchester, UK
| | - Yan Li
- Division of Informatics, Imaging & Data Sciences, University of Manchester, Manchester, UK
| | - Natalie Gold
- Behavioural Insights and Evaluation, Public Health England, London, UK
- Centre for Philosophy of Natural and Social Science, London School of Economics and Political Science, London, England
- Behavioural Practice, Kantar Public, London, England
| | - Tim Chadborn
- Behavioural Insights and Evaluation, Public Health England, London, UK
| | - William Welfare
- North West Health Protection Team, Public Health England North West, Manchester, UK
| | - Victoria Palin
- Division of Informatics, Imaging & Data Sciences, University of Manchester, Manchester, UK
| | - Darren M Ashcroft
- Centre for Pharmacoepidemiology and Drug Safety and NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester, UK
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27
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Leung MWY, Bazelier MT, Souverein PC, Uitdehaag BMJ, Klungel OH, Leufkens HGM, Pajouheshnia R. Mapping the risk of infections in patients with multiple sclerosis: A multi-database study in the United Kingdom Clinical Practice Research Datalink GOLD and Aurum. Mult Scler 2022; 28:1808-1818. [PMID: 35575214 PMCID: PMC9442628 DOI: 10.1177/13524585221094218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 02/18/2022] [Accepted: 03/21/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND People with multiple sclerosis (pwMS) have an increased risk of infections; risk factors include underlying disease, physical impairment and use of some disease-modifying treatments. OBJECTIVE To quantify changes in population-level infection rates among pwMS and compare these to the general population and people with rheumatoid arthritis (pwRA), and identify patient characteristics predictive of infections after MS diagnosis. METHODS We conducted a multi-database study using data on 23,226 people with MS diagnosis from the UK Clinical Practice Research Datalink Aurum and GOLD (January 2000-December 2020). PwMS were matched to MS-free controls and pwRA. We calculated infection rates, and estimated incidence rate ratios (IRR) and 95% confidence intervals (CI) of predictors for infections ⩽ 5 years after MS diagnosis using Poisson regression. RESULTS Among pwMS, overall infection rates remained stable - 1.51-fold (1.49-1.52) that in MS-free controls and 0.87-fold (0.86-0.88) that in pwRA - although urinary tract infection rate per 1000 person-years increased from 98.7 (96.1-101) (2000-2010) to 136 (134-138) (2011-2020). Recent infection before MS diagnosis was most predictive of infections (1 infection: IRR 1.92 (1.86-1.97); ⩾2 infections: IRR 3.00 (2.89-3.10)). CONCLUSION The population-level elevated risk of infection among pwMS has remained stable despite the introduction of disease-modifying treatments.
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Affiliation(s)
- Melissa WY Leung
- Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Department of Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, The Netherlands
| | - Marloes T Bazelier
- Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Department of Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, The Netherlands
| | - Patrick C Souverein
- Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Department of Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, The Netherlands
| | - Bernard MJ Uitdehaag
- Department of Neurology, Amsterdam Neuroscience, VUmc MS Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands
| | - Olaf H Klungel
- Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Department of Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, The Netherlands
| | - Hubert GM Leufkens
- Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Department of Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, The Netherlands
| | - Romin Pajouheshnia
- Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Department of Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, The Netherlands
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Nguyen NV, Do NTT, Vu DTV, Greer RC, Dittrich S, Vandendorpe M, Pham TN, Ta NTD, Pham TQ, Khuong VT, Le TTB, Anh LT, Cao TH, Trinh TS, Nguyen HT, Ngo LN, Vu TT, van Doorn HR, Lubell Y, Lewycka SO. Outpatient antibiotic prescribing for acute respiratory infections in Vietnamese primary care settings by the WHO AWaRe (Access, Watch and Reserve) classification: An analysis using routinely collected electronic prescription data. THE LANCET REGIONAL HEALTH - WESTERN PACIFIC 2022; 30:100611. [DOI: 10.1016/j.lanwpc.2022.100611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Schmiemann G, Hoffmann F, Hamprecht A, Jobski K. Patterns and trends of antibacterial treatment in patients with urinary tract infections, 2015–2019: an analysis of health insurance data. BMC PRIMARY CARE 2022; 23:204. [PMID: 35948891 PMCID: PMC9367112 DOI: 10.1186/s12875-022-01816-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 07/29/2022] [Indexed: 11/10/2022]
Abstract
Abstract
Background
Urinary tract infections are among the most common reason for encounter and subsequent antibiotic prescriptions. Due to the risk of collateral damage and increasing resistance rates, explicit recommendations against the use of fluoroquinolones like ciprofloxacin in uncomplicated urinary tract infections have been issued. However, to what extent these recommendations were followed and if there are relevant differences between the disciplines involved (general practitioners, urologists, paediatricians and gynaecologists) are unknown.
Methods
We used anonymized data from a local statutory health insurance (SHI) company, which covered about 38% of all SHI-insured persons in the federal state of Bremen, Germany between 2015—2019. Data included demographics, outpatient diagnoses and filled prescriptions on an individual level.
Results
One-year prevalence of urinary tract infections was 5.8% in 2015 (females: 9.2%, males: 2.5%). Of all 102,715 UTI cases, 78.6% referred to females and 21.4% to males, 6.0% of cases were younger than 18 years. In females, general practitioners were the most common diagnosing speciality (52.2%), followed by urologists (20.0%) and gynaecologists (16.1%). Overall, fluoroquinolones were most often prescribed (26.3%), followed by fosfomycin (16.1%) and the combination of sulfamethoxazole and trimethoprim (14.2%). Fluoroquinolones were most often prescribed by urologists and general practitioners, while gynaecologists preferred fosfomycin. During the study period, shares of fluoroquinolones decreased from 29.4% to 8.7% in females and from 45.9% to 22.3% in males.
Conclusions
Despite a clear trend toward a more guideline adherent prescription pattern, there is still room for improvement regarding the use of second-line antibiotics especially fluoroquinolones. The choice of antibiotics prescribed differs between specialities with higher uptake of guideline-recommended antibiotics by gynaecologists, mainly because of higher prescription shares of fosfomycin.
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Patey AM, Fontaine G, Francis JJ, McCleary N, Presseau J, Grimshaw JM. Healthcare professional behaviour: health impact, prevalence of evidence-based behaviours, correlates and interventions. Psychol Health 2022; 38:766-794. [PMID: 35839082 DOI: 10.1080/08870446.2022.2100887] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Healthcare professional (HCP) behaviours are actions performed by individuals and teams for varying and often complex patient needs. However, gaps exist between evidence-informed care behaviours and the care provided. Implementation science seeks to develop generalizable principles and approaches to investigate and address care gaps, supporting HCP behaviour change while building a cumulative science. We highlight theory-informed approaches for defining HCP behaviour and investigating the prevalence of evidence-based care and known correlates and interventions to change professional practice. Behavioural sciences can be applied to develop implementation strategies to support HCP behaviour change and provide valid, reliable tools to evaluate these strategies. There are thousands of different behaviours performed by different HCPs across many contexts, requiring different implementation approaches. HCP behaviours can include activities related to promoting health and preventing illness, assessing and diagnosing illnesses, providing treatments, managing health conditions, managing the healthcare system and building therapeutic alliances. The key challenge is optimising behaviour change interventions that address barriers to and enablers of recommended practice. HCP behaviours may be determined by, but not limited to, Knowledge, Social influences, Intention, Emotions and Goals. Understanding HCP behaviour change is a critical to ensuring advances in health psychology are applied to maximize population health.
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Affiliation(s)
- Andrea M. Patey
- Centre for Implementation Research, Ottawa Hospital Research Institute - General Campus, Ottawa, Ontario, Canada
| | - Guillaume Fontaine
- Centre for Implementation Research, Ottawa Hospital Research Institute - General Campus, Ottawa, Ontario, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jillian J. Francis
- Centre for Implementation Research, Ottawa Hospital Research Institute - General Campus, Ottawa, Ontario, Canada
- School of Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Nicola McCleary
- Centre for Implementation Research, Ottawa Hospital Research Institute - General Campus, Ottawa, Ontario, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Justin Presseau
- Centre for Implementation Research, Ottawa Hospital Research Institute - General Campus, Ottawa, Ontario, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jeremy M. Grimshaw
- Centre for Implementation Research, Ottawa Hospital Research Institute - General Campus, Ottawa, Ontario, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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Miller F, Zylbersztejn A, Favarato G, Adamestam I, Pembrey L, Shallcross L, Mason D, Wright J, Hardelid P. Factors predicting amoxicillin prescribing in primary care among children: a cohort study. Br J Gen Pract 2022; 72:BJGP.2021.0639. [PMID: 35817584 PMCID: PMC9282803 DOI: 10.3399/bjgp.2021.0639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 03/30/2022] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Antibiotic prescribing during childhood, most commonly for respiratory tract infections (RTIs), contributes to antimicrobial resistance, which is a major public health concern. AIM To identify factors associated with amoxicillin prescribing and RTI consultation attendance in young children in primary care. DESIGN AND SETTING Cohort study in Bradford spanning pregnancy to age 24 months, collected 2007-2013, linked to electronic primary care and air pollution data. METHOD Amoxicillin prescribing and RTI consultation rates/1000 child-years were calculated. Mixed-effects logistic regression models were fitted with general practice (GP) surgery as the random effect. RESULTS The amoxicillin prescribing rate among 2493 children was 710/1000 child-years during year 1 (95% confidence interval [CI] = 677 to 744) and 780/1000 (95% CI = 745 to 816) during year 2. During year 1, odds of amoxicillin prescribing were higher for boys (adjusted odds ratio [aOR] 1.36, 95% CI = 1.14 to 1.61), infants from socioeconomically deprived households (aOR 1.36, 95% CI = 1.00 to 1.86), and infants with a Pakistani ethnic background (with mothers born in the UK [aOR 1.44, 95% CI = 1.06 to 1.94] and outside [aOR 1.42, 95% CI = 1.07 to 1.90]). During year 2, odds of amoxicillin prescribing were higher for infants with a Pakistani ethnic background (with mothers born in the UK [aOR 1.46, 95% CI = 1.10 to 1.94] and outside [aOR 1.56, 95% CI = 1.19 to 2.04]) and those born <39 weeks gestation (aOR 1.20, 95% CI = 1.00 to 1.45). Additional risk factors included caesarean delivery, congenital anomalies, overcrowding, birth season, and childcare attendance, with GP surgery explaining 7%-9% of variation. CONCLUSION Socioeconomic status and ethnic background were associated with amoxicillin prescribing during childhood. Efforts to reduce RTI spread in household and childcare settings may reduce antibiotic prescribing in primary care.
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Affiliation(s)
- Faith Miller
- Institute for Global Health, University College London, London
| | - Ania Zylbersztejn
- Great Ormond Street Institute of Child Health, University College London, London
| | - Graziella Favarato
- Great Ormond Street Institute of Child Health, University College London, London
| | - Imad Adamestam
- College of Medicine and Veterinary Medicine, The University of Edinburgh, Edinburgh
| | - Lucy Pembrey
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London
| | - Laura Shallcross
- Institute of Health Informatics, University College London, London
| | - Dan Mason
- Bradford Institute for Health Research, Bradford
| | - John Wright
- Bradford Institute for Health Research, Bradford
| | - Pia Hardelid
- Great Ormond Street Institute of Child Health, University College London, London
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Impact of covid-19 on primary care contacts with children and young people aged 0-24 years in England; longitudinal trends study 2015-2020. Br J Gen Pract 2022; 72:e464-e471. [PMID: 35667683 PMCID: PMC9183461 DOI: 10.3399/bjgp.2021.0643] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 03/22/2022] [Indexed: 10/31/2022] Open
Abstract
Background: The NHS response to covid-19 altered provision and access to primary care. Aim: To examine the impact of covid-19 on general practitioner (GP) contacts with children and young people in England. Design and Setting: Longitudinal trends analysis using electronic health records from the Clinical Practice Research Datalink Aurum database. Methods: We included all children and young people younger than 25 years registered with a GP. We compared the number of total, remote and face-to-face contacts during the first UK lockdown (March to June 2020) with the mean contacts for comparable weeks from 2015 to 2019. Results: We examined 47 607 765 GP contacts with 4 307 120 million children and young people. GP contacts fell 41% during the first lockdown compared with previous years. Children aged 1-14 had greater falls in total contacts (>50%) compared with infants and 15-24s. Face-to-face contacts fell by 88% with the greatest falls occurring among children aged 1-14 (> 90%). Remote contacts more than doubled, increasing most in infants (over 2.5 fold). Total contacts for respiratory illnesses fell by 74% whereas contacts for common non-transmissible conditions shifted largely to remote, mitigating the total fall (31%). Conclusion: During the covid-19 pandemic, children and young people’s contact with GPs fell, particularly for face-to-face assessment. This may be explained by a lower prevalence of respiratory illnesses due to fewer social contacts and changing health care seeking behaviour. The large shift to remote contacts mitigated total falls in contacts for some age groups and for common non-transmissible conditions.
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Xingrong S, Rui F, Jing C, Jing C, Oliver I, Lambert H, Wang D. Relationships Between Diagnosis, Bacterial Isolation, and Antibiotic Prescription in Out Patients With Respiratory Tract Infection Symptoms in Rural Anhui, China. Front Public Health 2022; 10:810348. [PMID: 35223737 PMCID: PMC8864097 DOI: 10.3389/fpubh.2022.810348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 01/03/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectivesThis paper aims to explore the direct associations of antibiotics prescription with clinical diagnosis and bacterial detection. It also analyses the relations of clinical diagnosis with symptoms and bacterial detection, with a hope of revealing indirect links to antibiotic prescription.MethodsThe study was implemented in one village clinic and one township health center in each of four rural residential areas in Anhui Province, China. Observations were conducted to record clinical diagnosis and antibiotic prescription. A semi-structured questionnaire survey was used to collected patients' sociodemographic information and reported symptoms. Sputum and throat swabs were collected for bacterial culture.ResultsAmong 1,068 patients presenting in the study settings who received a diagnosis of respiratory tract infection (RTI), 87.8% of prescriptions included an antibiotic and 35.8% included two or more antibiotics. Symptomatic RTI patients to the site clinics were diagnosed mainly as having upper respiratory tract infection (32.0%), bronchitis/tracheitis (23.4%), others (16.6%), pharyngitis (11.1%), common cold (8.0%), pneumonia/bronchopneumonia (4.6%) and tonsillitis (4.3%). These clinical diagnosis were associated with symptoms to a varied degree especially for upper respiratory tract infection and bronchitis/tracheitis. Prescription of any antibiotics was positively associated with diagnosis of bronchitis/tracheitis (OR: 5.00, 95% CI: 2.63–9.51), tonsillitis (OR: 4.63, 95% CI: 1.48–14.46), pneumonia/bronchopneumonia (OR: 4.28, 95% CI: 1.40–13.04), pharyngitis (OR: 3.22, 95% CI: 1.57–6.59) and upper respiratory tract infection (OR: 3.04, 95% CI: 1.75–5.27). Prescription of two or more antibiotics was statistically significant related to diagnosis of bronchitis/ tracheitis (OR: 2.20, 95% CI: 1.44–3.35) or tonsillitis (OR: 2.97, 95% CI: 1.47–6.00). About 30% of the patients were identified with some type of bacteria. Bacteria detection was linked with pharyngitis (OR: 0.50, 95% CI: 0.28–0.88) but not prescription of antibiotics.ConclusionsAntibiotics prescription were found with a strong relation to diagnosis of RTIs given by the clinician but was not associated with the presence of bacteria in patient samples. Part of the diagnosis may have been given by the clinician to justify their antibiotics prescription. There is clear need to use additional measures (e.g., symptoms) in conjunction with diagnosis to supervise or audit excessive antibiotics use.
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Affiliation(s)
- Shen Xingrong
- School of Health Service Management, Anhui Medical University, Hefei, China
| | - Feng Rui
- Department of Literature Review and Analysis, Library of Anhui Medical University, Hefei, China
| | - Chai Jing
- School of Health Service Management, Anhui Medical University, Hefei, China
| | - Cheng Jing
- School of Health Service Management, Anhui Medical University, Hefei, China
| | - Isabel Oliver
- National Infection Service, Public Health England, Bristol, United Kingdom
| | - Helen Lambert
- Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Debin Wang
- School of Health Service Management, Anhui Medical University, Hefei, China
- *Correspondence: Debin Wang
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Borek AJ, Pouwels KB, van Hecke O, Robotham JV, Butler CC, Tonkin-Crine S. Role of locum GPs in antibiotic prescribing and stewardship: a mixed-methods study. Br J Gen Pract 2022; 72:e118-e127. [PMID: 34990397 PMCID: PMC8763197 DOI: 10.3399/bjgp.2021.0354] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 09/02/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Most antibiotics are prescribed in primary care. Locum or sessional GPs (locums) are perceived as contributing to higher prescribing and may face barriers to engaging with antimicrobial stewardship (AMS). AIM To identify how locums' antibiotic prescribing compares with other general practice prescribers, and how they perceive their role in antibiotic prescribing and AMS. DESIGN AND SETTING Mixed-methods study in primary care. METHOD Data on antibiotic prescribing, diagnoses, and patient and prescriber characteristics were extracted from The Health Improvement Network database. A mixed-effects logistic model was used to compare locums' and other prescribers' antibiotic prescribing for conditions that do not usually benefit from antibiotics. Nineteen semi-structured telephone interviews were conducted with locums in England and analysed thematically. RESULTS Locums accounted for 11% of consultations analysed. They prescribed antibiotics more often than other GPs and nurse prescribers for acute cough, sore throat, asthma and chronic obstructive pulmonary disease exacerbations, and acute bronchitis. The number of patients receiving antibiotics for these conditions was 4% higher (on absolute scale) when consulting with locums compared with when they consulted with other GPs. Four themes capture the perceived influences on prescribing antibiotics and AMS: antibiotic prescribing as a complex but individual issue, nature and patterns of locum work, relationships between practices and locums, and professional isolation. CONCLUSION Locums contribute to higher antibiotic prescribing compared with their peers. They experience challenges but also opportunities for contributing to AMS, which should be better addressed. With an increasing proportion of locums in general practice, they have an important role in antibiotic optimisation and AMS.
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Affiliation(s)
- Aleksandra J Borek
- National Institute for Health Research (NIHR) academic clinical lecturer
| | - Koen B Pouwels
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford
| | - Oliver van Hecke
- National Institute for Health Research (NIHR) academic clinical lecturer
| | - Julie V Robotham
- Antimicrobial Resistance, National Infection Service, Public Health England, London
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
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Dorgali MV, Longo A, Vass C, Shields G, Harrison R, Scarpa R, Boeri M. A General Public Study on Preferences and Welfare Impacts of Antimicrobial Resistance in the United Kingdom. PHARMACOECONOMICS 2022; 40:65-76. [PMID: 34458962 PMCID: PMC8403518 DOI: 10.1007/s40273-021-01076-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/01/2021] [Indexed: 05/09/2023]
Abstract
BACKGROUND Antibiotics have led to considerable increases in life expectancy. However, over time, antimicrobial resistance has accelerated and is now a significant global public health concern. Understanding societal preferences for the use of antibiotics as well as eliciting the willingness to pay for future research is crucial. OBJECTIVE To investigate preferences for different strategies to optimize antibiotic use and to understand the willingness to pay for future research in antimicrobial resistance and antimicrobial drug development. METHODS A discrete-choice experiment was administered to a sample of the UK general population. Respondents were asked to make nine choices, each offering three options-two hypothetical "doctor and antibiotics" and one "no doctor-no antibiotics"-defined by five attributes: treatment, days needed to recover, risk of bacterial infection that needs antibiotics, risk of common side effects, and risk of antimicrobial resistance by 2050. Data were analyzed using random parameters logit models. A double-bounded contingent valuation was also included in the survey to explore the willingness to pay for policies to contain antimicrobial resistance. RESULTS Among the 2579 respondents who completed the survey, 1151 always selected "no doctor-no antibiotics" and 57 never varied their choices; therefore, 1371 responses were used in the analysis. Risk of antimicrobial resistance by 2050 was the most important attribute and the "treatment" was the least important attribute, although this was sensitive to a higher risk of bacterial infection. The aggregate annual willingness to pay for containing antimicrobial resistance was approximately £8.35 billion (~£5-£10 billion). CONCLUSIONS The antimicrobial resistance risk is relevant and important to the general public. The high willingness to pay suggests that large investments in policies or interventions to combat antimicrobial resistance are justified.
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Affiliation(s)
- Maria Veronica Dorgali
- Queen's University Belfast, Belfast, UK
- Department Statistics, Informatics, Application "G. Parenti" (DISIA), University of Florence, Florence, Italy
| | | | - Caroline Vass
- RTI Health Solutions, RTI International, Manchester, UK
- Division of Population Health, Health Services Research & Primary Care, The University of Manchester, Manchester, UK
| | - Gemma Shields
- Division of Population Health, Health Services Research & Primary Care, The University of Manchester, Manchester, UK
| | - Roger Harrison
- Division of Population Health, Health Services Research & Primary Care, The University of Manchester, Manchester, UK
| | | | - Marco Boeri
- Queen's University Belfast, Belfast, UK.
- RTI Health Solutions, RTI International, Forsyth House, Cromac Square, Belfast, BT2 8LA, UK.
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Pagano F, Amato C, De Marco G, Micillo M, Cecere G, Poeta M, Guarino A, Lo Vecchio A. Reduction in broad-spectrum antimicrobial prescriptions by primary care pediatricians following a multifaceted antimicrobial stewardship program. Front Pediatr 2022; 10:1070325. [PMID: 36683814 PMCID: PMC9853423 DOI: 10.3389/fped.2022.1070325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 12/08/2022] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Since 2016, following the Italian "National Plan to Contrast Antimicrobial Resistance", Campania Region has implemented an antimicrobial stewardship program, including the obligation to associate an appropriate International Classification of Diseases-9 code to each antibiotic prescription, the publication of schemes for empirical antibiotic therapy and educational interventions. METHODS To evaluate the impact of these interventions on the prescribing habits of family pediatricians, we conducted a retrospective cohort study (January 2016-December 2020), including all patients registered in an associate practice of Primary Care Pediatricians. We collected data on antibiotic prescriptions through a specific study management software; our primary outcomes were the annual prescription rates, calculated for both the number of patients in follow-up and the number of medical consultations, and the annual prescription rates for selected antibiotic classes and molecules. To investigate the hypothesis that chronic conditions would be associated with an increased rate of prescription, we also tested the association between underlying conditions and the number of antibiotics received. RESULTS During the study period, 2,599 children received 11,364 antibiotic prescriptions (mean 4.37, SD 4.28). From 2016 to 2020 we observed a substantial reduction in both the annual prescription rate per 100 patients (9.33 to 3.39; R 2 = 0.927, p = 0.009), and the annual prescription rate per 100 medical consultations (25.49 to 15.98; R 2 = 0.996, p < 0.01). The prescription rates of Amoxicillin-Clavulanate (50.25 to 14.21; R 2 = 0.983, p = 0.001) and third generation Cephalosporins (28.43 to 5.43; R 2 = 0.995, p < 0.01) significantly decreased; we didn't find significant modifications in the prescription rates of Amoxicillin and Quinolones; finally, we observed a trend toward reduction in the prescription of Macrolides. No statistical association was found between antibiotics prescribing frequency and history of chronic diseases. DISCUSSION Following the implementation of the regional interventions on antimicrobial stewardship, we observed a substantial reduction in the overall antibiotic prescription per patients and per medical consultations, with a statistically significant reduction in the use of broad-spectrum molecules. Considering the results of our analysis, new guidance and training interventions addressed to specialists in the primary care sector should be implemented to further limit antibiotic resistance.
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Affiliation(s)
- F Pagano
- Department of Translational Medical Sciences, Section of Pediatrics, University of Naples Federico II, Naples, Italy
| | - C Amato
- Department of Translational Medical Sciences, Section of Pediatrics, University of Naples Federico II, Naples, Italy
| | - G De Marco
- U.O. Materno Infantile, ASL Napoli 1 Centro, Distretto Sanitario 28, Naples, Italy
| | - M Micillo
- U.O. Materno Infantile, ASL Napoli 1 Centro, Distretto Sanitario 28, Naples, Italy
| | - G Cecere
- U.O. Materno Infantile, ASL Napoli 1 Centro, Distretto Sanitario 28, Naples, Italy
| | - M Poeta
- Department of Translational Medical Sciences, Section of Pediatrics, University of Naples Federico II, Naples, Italy
| | - A Guarino
- Department of Translational Medical Sciences, Section of Pediatrics, University of Naples Federico II, Naples, Italy
| | - A Lo Vecchio
- Department of Translational Medical Sciences, Section of Pediatrics, University of Naples Federico II, Naples, Italy
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Ross M, Henao R, Burke TW, Ko ER, McClain MT, Ginsburg GS, Woods CW, Tsalik EL. A comparison of host response strategies to distinguish bacterial and viral infection. PLoS One 2021; 16:e0261385. [PMID: 34905580 PMCID: PMC8670660 DOI: 10.1371/journal.pone.0261385] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 11/29/2021] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Compare three host response strategies to distinguish bacterial and viral etiologies of acute respiratory illness (ARI). METHODS In this observational cohort study, procalcitonin, a 3-protein panel (CRP, IP-10, TRAIL), and a host gene expression mRNA panel were measured in 286 subjects with ARI from four emergency departments. Multinomial logistic regression and leave-one-out cross validation were used to evaluate the protein and mRNA tests. RESULTS The mRNA panel performed better than alternative strategies to identify bacterial infection: AUC 0.93 vs. 0.83 for the protein panel and 0.84 for procalcitonin (P<0.02 for each comparison). This corresponded to a sensitivity and specificity of 92% and 83% for the mRNA panel, 81% and 73% for the protein panel, and 68% and 87% for procalcitonin, respectively. A model utilizing all three strategies was the same as mRNA alone. For the diagnosis of viral infection, the AUC was 0.93 for mRNA and 0.84 for the protein panel (p<0.05). This corresponded to a sensitivity and specificity of 89% and 82% for the mRNA panel, and 85% and 62% for the protein panel, respectively. CONCLUSIONS A gene expression signature was the most accurate host response strategy for classifying subjects with bacterial, viral, or non-infectious ARI.
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Affiliation(s)
- Melissa Ross
- Duke University School of Medicine, Durham, NC, United States of America
| | - Ricardo Henao
- Duke Center for Applied Genomics & Precision Medicine, Duke University School of Medicine, Durham, NC, United States of America
- Department of Electrical and Computer Engineering, Duke University, Durham, NC, United States of America
| | - Thomas W. Burke
- Duke Center for Applied Genomics & Precision Medicine, Duke University School of Medicine, Durham, NC, United States of America
| | - Emily R. Ko
- Duke Center for Applied Genomics & Precision Medicine, Duke University School of Medicine, Durham, NC, United States of America
- Duke Regional Hospital, Durham, NC, United States of America
| | - Micah T. McClain
- Duke Center for Applied Genomics & Precision Medicine, Duke University School of Medicine, Durham, NC, United States of America
- Medical Service, Durham Veterans Affairs Health Care System, Durham, NC, United States of America
| | - Geoffrey S. Ginsburg
- Duke Center for Applied Genomics & Precision Medicine, Duke University School of Medicine, Durham, NC, United States of America
| | - Christopher W. Woods
- Duke Center for Applied Genomics & Precision Medicine, Duke University School of Medicine, Durham, NC, United States of America
- Medical Service, Durham Veterans Affairs Health Care System, Durham, NC, United States of America
| | - Ephraim L. Tsalik
- Duke Center for Applied Genomics & Precision Medicine, Duke University School of Medicine, Durham, NC, United States of America
- Emergency Medicine Service, Durham Veterans Affairs Health Care System, Durham, NC, United States of America
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Borek AJ, Campbell A, Dent E, Moore M, Butler CC, Holmes A, Walker AS, McLeod M, Tonkin-Crine S. Development of an intervention to support the implementation of evidence-based strategies for optimising antibiotic prescribing in general practice. Implement Sci Commun 2021; 2:104. [PMID: 34526140 PMCID: PMC8441243 DOI: 10.1186/s43058-021-00209-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 08/30/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Trials show that antimicrobial stewardship (AMS) strategies, including communication skills training, point-of-care C-reactive protein testing (POC-CRPT) and delayed prescriptions, help optimise antibiotic prescribing and use in primary care. However, the use of these strategies in general practice is limited and inconsistent. We aimed to develop an intervention to enhance uptake and implementation of these strategies in primary care. METHODS We drew on the Person-Based Approach to develop an implementation intervention in two stages. (1) Planning and design: We defined the problem in behavioural terms drawing on existing literature and conducting primary qualitative research (nine focus groups) in high-prescribing general practices. We identified 'guiding principles' with intervention objectives and key features and developed logic models representing intended mechanisms of action. (2) Developing the intervention: We created prototype intervention materials and discussed and refined these with input from 13 health professionals and 14 citizens in two sets of design workshops. We further refined the intervention materials following think-aloud interviews with 22 health professionals. RESULTS Focus groups highlighted uncertainties about how strategies could be used. Health professionals in the workshops suggested having practice champions, brief summaries of each AMS strategy and evidence supporting the AMS strategies, and they and citizens gave examples of helpful communication strategies/phrases. Think-aloud interviews helped clarify and shorten the text and user journey of the intervention materials. The intervention comprised components to support practice-level implementation: antibiotic champions, practice meetings with slides provided, and an 'implementation support' website section, and components to support individual-level uptake: website sections on each AMS strategy (with evidence, instructions, links to electronic resources) and material resources (patient leaflets, POC-CRPT equipment, clinician handouts). CONCLUSIONS We used a systematic, user-focussed process of developing a behavioural intervention, illustrating how it can be used in an implementation context. This resulted in a multicomponent intervention to facilitate practice-wide implementation of evidence-based strategies which now requires implementing and evaluating. Focusing on supporting the uptake and implementation of evidence-based strategies to optimise antibiotic use in general practice is critical to further support appropriate antibiotic use and mitigate antimicrobial resistance.
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Affiliation(s)
- Aleksandra J Borek
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.
| | - Anne Campbell
- National Institute for Health Research (NIHR) Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
| | - Elle Dent
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Michael Moore
- Primary Care Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Alison Holmes
- National Institute for Health Research (NIHR) Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
| | - A Sarah Walker
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford, UK
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Monsey McLeod
- National Institute for Health Research (NIHR) Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
- Centre for Medication Safety and Service Quality, Pharmacy Department, Imperial College Healthcare NHS Trust, London, UK
- NIHR Imperial Patient Safety Translational Research Centre, Imperial College London, London, UK
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
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Karasneh RA, Al-Azzam SI, Ababneh MA, Basheti IA, Al-Azzeh O, Al Sharie S, Conway BR, Aldeyab MA. Exploring Information Available to and Used by Physicians on Antibiotic Use and Antibiotic Resistance in Jordan. Antibiotics (Basel) 2021; 10:963. [PMID: 34439013 PMCID: PMC8389019 DOI: 10.3390/antibiotics10080963] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 08/03/2021] [Accepted: 08/06/2021] [Indexed: 11/16/2022] Open
Abstract
Evidence based information sources for physicians are needed for informed antibiotic prescribing practices. The aim of this study was to explore physicians' preferred sources of information and evaluate physicians' awareness of available information and initiatives on prudent antibiotic prescribing in Jordan. A cross-sectional study was conducted utilizing an online questionnaire and included physicians (n = 409) from all sectors and specialties in Jordan. Published guidelines (31.8%), the workplace (25.7%), colleagues or peers (20.0%), group or conference training (18.3%), and the medical professional body (18.1%) were the main sources of information about avoiding unnecessary antibiotic prescribing, with the influence of these sources on changing prescribers' views being 34.7%, 17.1%, 11%, 13.4%, and 7.6%, respectively. One-third of physicians (33.7%) reported no knowledge of any initiatives on antibiotic awareness and resistance. Regarding awareness of national action plans on antimicrobial resistance, 10.5%, 34%, and 55.5% of physicians were aware, unaware, and unsure of the presence of any national action plans, respectively. Physicians showed interest in receiving more information on resistance to antibiotics (58.9%), how to use antibiotics (42.2%), medical conditions for which antibiotics are used (41.3%), prescribing of antibiotics (35.2%), and links between the health of humans, animals, and the environment (19.8%). The findings can inform interventions needed to design effective antimicrobial stewardship, enabling physicians to prescribe antibiotics appropriately.
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Affiliation(s)
- Reema A. Karasneh
- Department of Basic Medical Sciences, Faculty of Medicine, Yarmouk University, Irbid 21163, Jordan;
| | - Sayer I. Al-Azzam
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid 22110, Jordan; (S.I.A.-A.); (M.A.A.)
| | - Mera A. Ababneh
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid 22110, Jordan; (S.I.A.-A.); (M.A.A.)
| | - Iman A. Basheti
- Faculty of Pharmacy, Applied Sciences Private University, Amman 11931, Jordan;
| | - Ola Al-Azzeh
- Department of Pharmacy Practice, College of Pharmacy, King Saud Bin Abdulaziz University for Health Sciences, Riyadh 11481, Saudi Arabia;
| | - Sarah Al Sharie
- Faculty of Medicine, Yarmouk University, Irbid 21163, Jordan;
| | - Barbara R. Conway
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield HD1 3DH, UK;
- Institute of Skin Integrity and Infection Prevention, University of Huddersfield, Huddersfield HD1 3DH, UK
| | - Mamoon A. Aldeyab
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield HD1 3DH, UK;
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van Staa TP, Palin V, Brown B, Welfare W, Li Y, Ashcroft DM. The Safety of Delayed Versus Immediate Antibiotic Prescribing for Upper Respiratory Tract Infections. Clin Infect Dis 2021; 73:e394-e401. [PMID: 32594104 PMCID: PMC8282258 DOI: 10.1093/cid/ciaa890] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 06/24/2020] [Indexed: 12/15/2022] Open
Abstract
Background This study aimed to evaluate the clinical safety of delayed antibiotic prescribing for upper respiratory tract infections (URTIs), which is recommended in treatment guidelines for less severe cases. Methods Two population-based cohort studies used the English Clinical Practice Research Databank and Welsh Secure Anonymized Information Linkage, containing electronic health records from primary care linked to hospital admission records. Patients with URTI and prescriptions of amoxicillin, clarithromycin, doxycycline, erythromycin, or phenoxymethylpenicillin were identified. Patients were stratified according to delayed and immediate prescribing relative to URTI diagnosis. Outcome of interest was infection-related hospital admission after 30 days. Results The population included 1.82 million patients with an URTI and antibiotic prescription; 91.7% had an antibiotic at URTI diagnosis date (immediate) and 8.3% had URTI diagnosis in 1–30 days before (delayed). Delayed antibiotic prescribing was associated with a 52% increased risk of infection-related hospital admissions (adjusted hazard ratio, 1.52; 95% confidence interval, 1.43–1.62). The probability of delayed antibiotic prescribing was unrelated to predicted risks of hospital admission. Analyses of the number needed to harm showed considerable variability across different patient groups (median with delayed antibiotic prescribing, 1357; 2.5% percentile, 295; 97.5% percentile, 3366). Conclusions This is the first large population-based study examining the safety of delayed antibiotic prescribing. Waiting to treat URTI was associated with increased risk of hospital admission, although delayed antibiotic prescribing was used similarly between high- and low-risk patients. There is a need to better target delayed antibiotic prescribing to URTI patients with lower risks of complications.
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Affiliation(s)
- Tjeerd Pieter van Staa
- Centre for Health Informatics, Division of Informatics, Imaging, and Data Science, School of Health Sciences, Faculty of Biology, Medicine, and Health, The University of Manchester, Manchester, United Kingdom.,Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Victoria Palin
- Centre for Health Informatics, Division of Informatics, Imaging, and Data Science, School of Health Sciences, Faculty of Biology, Medicine, and Health, The University of Manchester, Manchester, United Kingdom
| | - Benjamin Brown
- Centre for Health Informatics, Division of Informatics, Imaging, and Data Science, School of Health Sciences, Faculty of Biology, Medicine, and Health, The University of Manchester, Manchester, United Kingdom
| | - William Welfare
- Public Health England North West, Manchester, United Kingdom
| | - Yan Li
- Centre for Health Informatics, Division of Informatics, Imaging, and Data Science, School of Health Sciences, Faculty of Biology, Medicine, and Health, The University of Manchester, Manchester, United Kingdom
| | - Darren M Ashcroft
- Centre for Pharmacoepidemiology and Drug Safety, School of Health Sciences, Faculty of Biology, Medicine, and Health, The University of Manchester, Manchester, United Kingdom.,NIHR Greater Manchester Patient Safety Translational Research Centre, School of Health Sciences, Faculty of Biology, Medicine, and Health, The University of Manchester, Manchester, United Kingdom
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Radošević Quadranti N, Vlahović-Palčevski V, Popović B, Diminić-Lisica I. Impact of guidelines on antibiotic prescribing approach in primary care-a 10-year study. Fam Pract 2021; 38:259-264. [PMID: 33215207 DOI: 10.1093/fampra/cmaa125] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Publication and implementation of clinical guidelines is an important educational measure that considerably helps physicians in choosing appropriate antimicrobial drug. OBJECTIVES To evaluate long-term changes in antimicrobial prescribing habits before and after publishing the guidelines and to determine the factors that influence physician's decision to prescribe an antimicrobial drug. METHODS The study among general practitioners in Primorsko-Goranska County was conducted in three periods (January 2009, January 2011 and April 2019) by using a structured questionnaire that included general data about the physician, questions about their habits in antibiotic prescribing, criteria that influenced decision to prescribe antibiotics and antimicrobial agent(s) preferred in treating common infections. RESULTS Concomitant chronic (non-pulmonary) disease was the most important factor influencing decision to prescribe an antimicrobial drug. Over 88% of physicians that completed the survey declared themselves as rational prescribers of antimicrobials but more than half of them (53.3%) sometimes prescribed an antibiotic even though it was not indicated compared to 75% of self-reported non-rational prescribers (P ˂ 0.05). Self-reported adherence to the guidelines increased from 34.6% in 2011 to 51.8% in 2019. CONCLUSION The research showed improvement in physicians' knowledge in choosing the right antibiotic based on the analysis of answers but indicated the necessity for improving communication skills and empowering physicians not to prescribe antibiotics 'just in case' because of diagnostic uncertainty or patient demand. Further qualitative research is needed to understand physicians' prescribing behaviour and decision-making processes in order to develop interventions that will effectively improve the use of antibiotics.
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Affiliation(s)
| | - Vera Vlahović-Palčevski
- Faculty of Health Studies, University of Rijeka, Rijeka.,Medical Faculty, University of Rijeka, Rijeka.,Department of Clinical Pharmacology, University Hospital Rijeka, Rijeka
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Stuart B, Brotherwood H, Van't Hoff C, Brown A, van den Bruel A, Hay AD, Moore M, Little P. Exploring the appropriateness of antibiotic prescribing for common respiratory tract infections in UK primary care. J Antimicrob Chemother 2021; 75:236-242. [PMID: 31637421 DOI: 10.1093/jac/dkz410] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 08/13/2019] [Accepted: 08/29/2019] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVES To use illness severity scores to evaluate the appropriateness of antibiotic prescribing in UK general practice. METHODS We describe variations in practice prescribing rates, taking account of illness severity. We used three scores in three studies to measure severity: 'FeverPAIN' in an adult acute sore throat cohort (n=12 829), the '3C score' in an adult acute lower respiratory tract infection cohort (n=28 883) and the STARWAVe score in an acute cough and respiratory infection children's cohort (n=8394). We calculated median ORs to quantify practice-level variation in prescribing rates, adjusted for illness severity. RESULTS There was substantial variability in practice prescribing rates (ranges of 0%-97%, 7%-100% and 0%-75% in the three cohorts, respectively). There was evidence that higher prescribing practices saw a higher proportion of unwell patients. At the individual level, patients who were more unwell were more likely to receive a prescription, but prescribing levels for those with low scores were still high. The median OR was 2.5 (95% credible interval=2.2-2.9) in the sore throat data set, 2.9 (95% credible interval=2.6-3.2) in the adult cough data set and 2.1 (95% credible interval=1.8-2.4) in the children's cough data set. CONCLUSIONS Higher prescribing practices may see more unwell patients with high illness severity scores, but the differences in scores account for a minority of between-practice prescribing variation. There is likely to be scope for further reductions in antibiotic prescribing among patients with low illness severity scores. Further research is needed to explore the additional factors that account for variation in prescribing levels.
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Affiliation(s)
- Beth Stuart
- University of Southampton, Primary Care Medical Group, PCPS Unit, Aldermoor Health Centre, Southampton, UK
| | - Hannah Brotherwood
- University of Southampton, Primary Care Medical Group, PCPS Unit, Aldermoor Health Centre, Southampton, UK
| | - Catherine Van't Hoff
- University of Southampton, Primary Care Medical Group, PCPS Unit, Aldermoor Health Centre, Southampton, UK
| | - Alastair Brown
- University of Southampton, Primary Care Medical Group, PCPS Unit, Aldermoor Health Centre, Southampton, UK
| | | | - Alastair D Hay
- Centre for Academic Primary Care, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
| | - Michael Moore
- University of Southampton, Primary Care Medical Group, PCPS Unit, Aldermoor Health Centre, Southampton, UK
| | - Paul Little
- University of Southampton, Primary Care Medical Group, PCPS Unit, Aldermoor Health Centre, Southampton, UK
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43
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Armstrong D, Dregan A, Ashworth M, White P, McGee C, de Lusignan S. Comment on: Influence of prior antibiotic use on risk of rheumatoid arthritis: case-control study in general practice. Reply. Rheumatology (Oxford) 2021; 60:e150. [PMID: 33241417 DOI: 10.1093/rheumatology/keaa679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 09/16/2020] [Indexed: 11/14/2022] Open
Affiliation(s)
- David Armstrong
- School of Population Health and Environmental Sciences, King's College London, London, UK
| | - Alex Dregan
- Department of Psychological Medicine, Institute of Psychiatry, Psychology, and Neurosciences, King's College London, London, UK
| | - Mark Ashworth
- School of Population Health and Environmental Sciences, King's College London, London, UK
| | - Patrick White
- School of Population Health and Environmental Sciences, King's College London, London, UK
| | - Chris McGee
- Department of Clinical and Experimental Medicine, Surrey University, Guildford, UK.,Royal College of General Practitioners Research and Surveillance Centre, London, UK
| | - Simon de Lusignan
- Department of Clinical and Experimental Medicine, Surrey University, Guildford, UK.,Royal College of General Practitioners Research and Surveillance Centre, London, UK
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Derbyshire EJ, Calder PC. Respiratory Tract Infections and Antibiotic Resistance: A Protective Role for Vitamin D? Front Nutr 2021; 8:652469. [PMID: 33842525 PMCID: PMC8027331 DOI: 10.3389/fnut.2021.652469] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 02/15/2021] [Indexed: 12/11/2022] Open
Abstract
Upper and lower respiratory tract infections are among the most common infections globally, and in the United Kingdom, they account for about half of all oral antibiotics prescribed. Antibiotic overuse and the emergence of "superbugs" that are resistant to their effects is a global problem that is becoming a serious concern. Considering this, the potential role of immunonutrition as a "prehabilitation" in helping to tackle bacterial infections and reduce over-reliance on antibiotic usage is gaining interest. This narrative mini-review summarizes current knowledge on the roles of certain nutrients in helping to modulate immune function, with particular focus on vitamin D. Vitamin D supplementation appears to reduce the risk of acute respiratory tract infections and thus could have a valuable role to play in reducing over-reliance on antibiotics. Investment in high-quality trials is needed to further explore this field.
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Affiliation(s)
| | - Philip C. Calder
- Faculty of Medicine, School of Human Development and Health, University of Southampton, Southampton, United Kingdom
- National Institute for Health Research Southampton Biomedical Research Center, University Hospital Southampton National Health Service Foundation Trust and University of Southampton, Southampton, United Kingdom
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45
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Palin V, Welfare W, Ashcroft DM, van Staa TP. Shorter and longer courses of antibiotics for common infections and the association with reductions of infection-related complications including hospital admissions. Clin Infect Dis 2021; 73:1805-1812. [PMID: 33623985 PMCID: PMC8599204 DOI: 10.1093/cid/ciab159] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Antimicrobial resistance is a serious global health concern that emphasises completing treatment course. Recently, the effectiveness of short versus longer antibiotic courses has been questioned. This study investigated the duration of prescribed antibiotics, their effectiveness and associated risk of infection-related complications. METHODS Clinical Practice Research Datalink identified 4 million acute infection episodes prescribed an antibiotic in primary care between January 2014 - June 2014, England. Prescriptions were categorised by duration. Risk of infection-related hospitalisations within 30 days was modelled overall and by infection type. Risk was assessed immediately after or within 30 days follow-up to measure confounders given similar and varying exposure respectively. An interaction term with follow-up time assessed whether hazards ratios (HR) remained parallel with different antibiotic durations. RESULTS The duration of antibiotic courses increased over the study period (5.2-19.1%); 6-7 days were most common (66.9%). Most infection-related hospitalisations occurred with prescriptions of 8-15 days (0.21%), accompanied by greater risk of infection-related complications compared to patients that received a short prescription (HR 1.75 [95% CI 1.54-2.00]). Comparing HRs in the first 5 days versus remaining follow-up showed longer antibiotic courses were no more effective than shorter courses (1.02 [95% CI 0.90-1.16] and 0.92 [95% CI 0.75-1.12]). No variation by infection-type was observed. CONCLUSION Equal effectiveness was found between shorter and longer antibiotic courses and the reduction of infection-related hospitalisations. Stewardship programmes should recommend shorter courses of antibiotics for acute infections. Further research is required for treating patients with a complex medical history.
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Affiliation(s)
- Victoria Palin
- Centre for Health Informatics, Health Data Research UK North, School of Health Sciences, Faculty of Biology, Medicine and Health, the University of Manchester, Oxford Road, Manchester, UK
| | - William Welfare
- Public Health England North West, 3 Piccadilly Place, London Road, Manchester, UK
| | - Darren M Ashcroft
- Centre for Pharmacoepidemiology and Drug Safety, School of Health Sciences, Faculty of Biology, Medicine and Health, the University of Manchester, Oxford Road, Manchester, UK.,NIHR Greater Manchester Patient Safety Translational Research Centre, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Oxford Road, Manchester, UK
| | - Tjeerd Pieter van Staa
- Centre for Health Informatics, Health Data Research UK North, School of Health Sciences, Faculty of Biology, Medicine and Health, the University of Manchester, Oxford Road, Manchester, UK.,Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands
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46
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Borek AJ, Campbell A, Dent E, Butler CC, Holmes A, Moore M, Walker AS, McLeod M, Tonkin-Crine S. Implementing interventions to reduce antibiotic use: a qualitative study in high-prescribing practices. BMC FAMILY PRACTICE 2021; 22:25. [PMID: 33485324 PMCID: PMC7825381 DOI: 10.1186/s12875-021-01371-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 01/09/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Trials have shown that delayed antibiotic prescriptions (DPs) and point-of-care C-Reactive Protein testing (POC-CRPT) are effective in reducing antibiotic use in general practice, but these were not typically implemented in high-prescribing practices. We aimed to explore views of professionals from high-prescribing practices about uptake and implementation of DPs and POC-CRPT to reduce antibiotic use. METHODS This was a qualitative focus group study in English general practices. The highest antibiotic prescribing practices in the West Midlands were invited to participate. Clinical and non-clinical professionals attended focus groups co-facilitated by two researchers. Focus groups were audio-recorded, transcribed verbatim and analysed thematically. RESULTS Nine practices (50 professionals) participated. Four main themes were identified. Compatibility of strategies with clinical roles and experience - participants viewed the strategies as having limited value as 'clinical tools', perceiving them as useful only in 'rare' instances of clinical uncertainty and/or for those less experienced. Strategies as 'social tools' - participants perceived the strategies as helpful for negotiating treatment decisions and educating patients, particularly those expecting antibiotics. Ambiguities - participants perceived ambiguities around when they should be used, and about their impact on antibiotic use. Influence of context - various other situational and practical issues were raised with implementing the strategies. CONCLUSIONS High-prescribing practices do not view DPs and POC-CRPT as sufficiently useful 'clinical tools' in a way which corresponds to the current policy approach advocating their use to reduce clinical uncertainty and improve antimicrobial stewardship. Instead, policy attention should focus on how these strategies may instead be used as 'social tools' to reduce unnecessary antibiotic use. Attention should also focus on the many ambiguities (concerns and questions) about, and contextual barriers to, using these strategies that need addressing to support wider and more consistent implementation.
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Affiliation(s)
- Aleksandra J Borek
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.
| | - Anne Campbell
- National Institute for Health Research (NIHR) Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
| | - Elle Dent
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Alison Holmes
- National Institute for Health Research (NIHR) Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
| | - Michael Moore
- Primary Care Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton, UK
| | - A Sarah Walker
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK.,NIHR Oxford Biomedical Research Centre, Oxford, UK.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Monsey McLeod
- National Institute for Health Research (NIHR) Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK.,Centre for Medication Safety and Service Quality, Pharmacy Department, Imperial College Healthcare NHS Trust, London, UK.,NIHR Imperial Patient Safety Translational Research Centre, Imperial College London, London, UK
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.,NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
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47
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Fernández-Urrusuno R, Meseguer Barros CM, Anaya-Ordóñez S, Borrego Izquierdo Y, Lallana-Álvarez MJ, Madridejos R, Tejón EM, Sánchez RP, Pérez Rodríguez O, García Gil M, Escudero Vilaplana B, Riádigos GMS, López-Fando MSP, Olmo Quintana V, Pina Gadea MB, García Alvarez A, Martorell MLS, Jiménez Arce JI, Aguilella Vizcaíno R, Pérez Martín J, Alzueta Isturiz N. Patients receiving a high burden of antibiotics in the community in Spain: a cross-sectional study. Pharmacol Res Perspect 2020; 9:e00692. [PMID: 33340264 PMCID: PMC7749514 DOI: 10.1002/prp2.692] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 10/26/2020] [Accepted: 11/02/2020] [Indexed: 02/06/2023] Open
Abstract
Some patients in the community receive a high burden of antibiotics. We aimed at describing the characteristics of these patients, antibiotics used, and conditions for which they received antibiotics. We carried out a cross-sectional study. Setting: Thirty Health Primary Care Areas from 12 regions in Spain, covering 5,960,191 inhabitants. Patients having at least 30 packages of antibacterials for systemic use dispensed in 2017 were considered. Main outcome measures: Prevalence of antibiotic use, conditions for which antibiotics were prescribed, clinical characteristics of patients, comorbidities, concomitant treatments, and microbiological isolates. Patient's average age was 70 years; 52% were men; 60% smokers/ex-smokers; 54% obese. Overall, 93% of patients had, at least, one chronic condition, and four comorbidities on average. Most common comorbidities were cardiovascular and/or hypertension (67%), respiratory diseases (62%), neurological/mental conditions (32%), diabetes (23%), and urological diseases (21%); 29% were immunosuppressed, 10% were dead at the time of data collection. Patients received three antibiotic treatments per year, mainly fluoroquinolones (28%), macrolides (21%), penicillins (19%), or cephalosporins (12%). Most frequently treated conditions were lower respiratory tract (infections or prophylaxis) (48%), urinary (27%), and skin/soft tissue infections (11%). Thirty-five percent have been guided by a microbiological diagnosis, being Pseudomonas aeruginosa (30%) and Escherichia coli (16%) the most frequent isolates. In conclusion, high antibiotic consumers in the community were basically elder, with multimorbidity and polymedication. They frequently received broad-spectrum antibiotics for long periods of time. The approach to infections in high consumers should be differentiated from healthy patients receiving antibiotics occasionally.
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Affiliation(s)
- Rocío Fernández-Urrusuno
- Clinical Unit Primary Care Pharmacy Sevilla, Aljarafe-Sevilla Norte Primary Health Area, Andalusian Health Service, Seville, Spain
| | | | - Sonia Anaya-Ordóñez
- Service of Pharmacy, Granada Metropolitano Primary Health Care Area, Andalusian Health Service, Granada, Spain
| | | | | | | | - Esther Marco Tejón
- Cuenca Primary Care Management, Hospital Virgen de la Luz, Castilla La Mancha Health Service, Cuenca, Spain
| | | | - Olatz Pérez Rodríguez
- Mallorca Primary Care Management, Islas Baleares Health Service IB-SALUT, Palma de Mallorca, Spain
| | - María García Gil
- Service of Pharmacy, Sagunto Health Care Area, Comunidad Valenciana, Valencia, Spain
| | | | - Genma M Silva Riádigos
- Service of Pharmacy, Ouest Primary Health Care Area, Madrid Health Service, Madrid, Spain
| | | | - Vicente Olmo Quintana
- Service of Pharmacy, Gran Canaria Primary Care Management, Canarian Health Service, Gran Canaria, Spain
| | - M Belén Pina Gadea
- Service of Primary Care Pharmacy, Aragón Health Service, Zaragoza, Spain
| | - Angel García Alvarez
- Tramuntana Primary Care Management, Islas Baleares Health Care Service, Palma de Mallorca, Spain
| | - M Llüisa Sastre Martorell
- Service of Pharmacy, Hospital Universitari Son Espases, Islas Baleares Health Service IB-SALUT, Palma de Mallorca, Spain
| | - Jorge I Jiménez Arce
- Clinical Unit Primary Care Pharmacy Area VII Asturias, Principado de Asturias Health Service, Mieres, Asturias, Spain
| | | | - Joaquín Pérez Martín
- Faculty of Social Sciences, Area of Design, Gaming and Multimedia, European University of Madrid, Madrid, Spain
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48
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Borek AJ, Anthierens S, Allison R, Mcnulty CAM, Anyanwu PE, Costelloe C, Walker AS, Butler CC, Tonkin-Crine S. Social and Contextual Influences on Antibiotic Prescribing and Antimicrobial Stewardship: A Qualitative Study with Clinical Commissioning Group and General Practice Professionals. Antibiotics (Basel) 2020; 9:E859. [PMID: 33271843 PMCID: PMC7759918 DOI: 10.3390/antibiotics9120859] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 11/20/2020] [Accepted: 11/26/2020] [Indexed: 12/25/2022] Open
Abstract
Antibiotic prescribing in England varies considerably between Clinical Commissioning Groups (CCGs) and general practices. We aimed to assess social and contextual factors affecting antibiotic prescribing and engagement with antimicrobial stewardship (AMS) initiatives. Semi-structured telephone interviews were conducted with 22 CCG professionals and 19 general practice professionals. Interviews were audio-recorded, transcribed, and analyzed thematically. Social/contextual influences were grouped into the following four categories: (1) Immediate context, i.e., patients' social characteristics (e.g., deprivation and culture), clinical factors, and practice and clinician characteristics (e.g., "struggling" with staff shortage/turnover) were linked to higher prescribing. (2) Wider context, i.e., pressures on the healthcare system, limited resources, and competing priorities were seen to reduce engagement with AMS. (3) Collaborative and whole system approaches, i.e., communication, multidisciplinary networks, leadership, and teamwork facilitated prioritizing AMS, learning, and consistency. (4) Relativity of appropriate prescribing, i.e., "high" or "appropriate" prescribing was perceived as relative, depending on comparators, and disregarding different contexts, but social norms around antibiotic use among professionals and patients seemed to be changing. Further optimization of antibiotic prescribing would benefit from addressing social/contextual factors and addressing wider health inequalities, not only targeting individual clinicians. Tailoring and adapting to local contexts and constraints, ensuring adequate time and resources for AMS, and collaborative, whole system approaches to promote consistency may help promote AMS.
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Affiliation(s)
- Aleksandra J. Borek
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK; (C.C.B.); (S.T.-C.)
| | - Sibyl Anthierens
- Department of Family Medicine and Population Health, University of Antwerp, 2610 Antwerp, Belgium;
| | - Rosalie Allison
- Primary Care and Interventions Unit, Public Health England, Gloucester GL1 1DQ, UK; (R.A.); (C.A.M.M.)
| | - Cliodna A. M. Mcnulty
- Primary Care and Interventions Unit, Public Health England, Gloucester GL1 1DQ, UK; (R.A.); (C.A.M.M.)
| | - Philip E. Anyanwu
- Department of Primary Care and Public Health, Imperial College London, London W6 8RP, UK; (P.E.A.); (C.C.)
- School of Medicine, College of Biomedical and Life Sciences, Cardiff University, Cardiff CF14 4XN, UK
| | - Ceire Costelloe
- Department of Primary Care and Public Health, Imperial College London, London W6 8RP, UK; (P.E.A.); (C.C.)
| | - Ann Sarah Walker
- National Institute for Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Oxford OX3 9DU, UK;
- National Institute for Health Research Biomedical Research Centre, Oxford OX3 9DU, UK
- Nuffield Department of Medicine, University of Oxford, Oxford OX3 9DU, UK
| | - Christopher C. Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK; (C.C.B.); (S.T.-C.)
- National Institute for Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Oxford OX3 9DU, UK;
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK; (C.C.B.); (S.T.-C.)
- National Institute for Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Oxford OX3 9DU, UK;
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Doherty TM, Hausdorff WP, Kristinsson KG. Effect of vaccination on the use of antimicrobial agents: a systematic literature review. Ann Med 2020; 52:283-299. [PMID: 32597236 PMCID: PMC7880080 DOI: 10.1080/07853890.2020.1782460] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Antimicrobial resistance is a growing global health threat. To preserve the effectiveness of antimicrobials, it is important to reduce demand for antimicrobials. OBJECTIVES The objective of the study was to screen the existing peer-reviewed literature to identify articles that addressed the potential impact of influenza or Pneumococcus vaccination on antibiotic usage. Data sources: PubMed, Embase Study eligibility criteria: Clinical studies where antimicrobial prescribing was assessed in both vaccinated and unvaccinated populations. Participants and interventions: All patient populations were included (infants, children, adults and elderly), where the effects of the intervention (vaccination) was assessed. RESULTS We identified unique 3638 publications, of which 26 were judged to be of sufficiently high quality to allow the calculation of the potential impact of vaccination. Of these studies 23/26 found a significant reduction in antibiotic use by at least one of the parameters assessed. LIMITATIONS Different measures used to define anti-microbial use, studies typically focus on specific risk groups and most studies are from high-income countries. Conclusions and implications of key findings: Despite the limitations of the review, the evidence indicates that improved coverage with existing vaccines may significantly reduce antimicrobial demand. This suggests it may be a valuable tool for antimicrobial stewardship. Key messages While vaccines against a number of pathogens have been studied for their ability to reduce antimicrobial use, currently only vaccination against influenza or pneumococcus has generated sufficient data for analysis Vaccination against either influenza or pneumococcus significantly reduced overall antimicrobial prescribing rates, both in vaccinated individuals and at a population level Maintaining and expanding vaccination coverage thus appears to be a key tool for antimicrobial stewardship.
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Affiliation(s)
| | - William P Hausdorff
- PATH, Washington, DC, USA.,Faculty of Medicine, Université Libre de Bruxelles, Brussels, Belgium
| | - Karl G Kristinsson
- Department of Clinical Microbiology, Landspitali University Hospital, Reykjavík, Iceland.,Faculty of Medicine, University of Iceland, Reykjavík, Iceland
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50
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Stedman M, Lunt M, Davies M, Fulton-McAlister E, Hussain A, van Staa T, Anderson SG, Heald AH. Controlling antibiotic usage-A national analysis of General Practitioner/Family Doctor practices links overall antibiotic levels to demography, geography, comorbidity factors with local discretionary prescribing choices. Int J Clin Pract 2020; 74:e13515. [PMID: 32306458 DOI: 10.1111/ijcp.13515] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 03/26/2020] [Accepted: 04/13/2020] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Ecological studies show association between antimicrobial resistance (AMR), and inappropriate oral antibiotics use. Moderating antibiotic prescribing requires an understanding of all drivers of local prescribing. The aim was to quantify how much is determined by external factors compared with discretionary clinical choices. METHODS Oral antibiotic usage taken from England General Practitioner/Family Doctor practice prescribing data was aggregated using WHO/ATC defined daily doses (DDDs). The average annual antibiotic daily prescribing rate (AAADPR) in each practice was the total DDD of oral antibiotics divided by registered population and 365. The AAADPR of English practices in 2017_18 was linked by regression to factors including demographics, geography, medical comorbidities, clinical performance, patient satisfaction, medical workforce characteristics and prescribing selection. The regression coefficients for modifiable prescribing selection factors were applied to the difference between the median and top decile practice values to establish overall reduction opportunities through changing prescribing behaviour. RESULTS Twenty five factors accounted for 58% of the AAADPR variation in 5889 practices supporting 49.8 million patients. Non-modifiable factors linked increased AAADPR to more northerly location, higher prevalence of diabetes, COPD, CHD, and asthma; higher white ethnicity; higher patient satisfaction and lower population density. Modifiable behaviour accounted for 11% of the variation in AAADPR, with increases associated with a wider range of antibiotics, higher proportion taken as liquids, higher doses in each prescription, lower guideline compliance, lower targeted antibiotics, lower spend/dose, and less seasonal variation. If all practices achieved the level of modifiable factors of the top decile, this model suggests that overall AAADPR could reduce by 31%. CONCLUSION Such analysis is associative and does not infer causation. However, demographics, location, medical condition of the population, and prescribing selection are drivers of overall antibiotic prescribing. This analysis provides benchmarks for both non-modifiable and modifiable factors against which practices could evaluate their opportunities to reduce antibiotic prescribing.
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Affiliation(s)
| | - Mark Lunt
- The School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
| | | | - Erin Fulton-McAlister
- Centre for Molecular Bacteriology and Infection, Imperial College London, London, UK
| | | | - Tjeerd van Staa
- School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Simon G Anderson
- The School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
- The George Alleyne Chronic Disease Research Centre, University of the West Indies, Cavehill, Barbados
| | - Adrian H Heald
- The School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
- Department of Diabetes and Endocrinology, Salford Royal Hospital, Salford, UK
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